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It's taking while should be there any minute. Mm. It's not going to live for some reason. I think I can see like the little, yeah, so it's load. Um, but it has to go. Yeah, there we go. Hello, everyone. Welcome back to the Five Academy of Revision tutorials. We'll be covering pediatrics today and we're very lucky to be joined by Susana, a final year medical student. Ever to you, Susanna. Hi. My name is Suzanna. Uh, I'm, as Lucas mentioned, I'm a finally a medical student. Um, and today I'll try to, um, cover some of the most important topics from piece just as a quick provisions before your exams. Um, so there will be some questions of some X M secure questions to answer as we go along through the slides and, um, just a couple of things to mention before we start. So, um, it's quite impossible to cover everything in two hours. So we will cover some of some of the most important topics uh from piece. But there, there will be some which we want to discuss today. So, um, just bear that in mind. And the second thing is that we have a lot of slides to go through. Uh, so the I'll try to explain things, uh, as clearly as, as I can, but the pace could be a little bit too fast for some people. So, uh, let me know if you have any issues with kind of understanding by explanations. Uh, and I'll try to, um, check the chat, um, uh, throughout the, uh, the whole tutorial just to check if there are any questions. Um, okay, you can see there are some already some people here. Okay. So, well, in the interest of time we will just crack on. Uh, let me make the slides a little bit bigger. Okay, perfect. Uh, so, um, as I said, these are the, uh, it's impossible to cover everything and these are the top, the kind of lost supported Pete's topic that we're going to cover today. Uh However, there are other things, for example, uh, bronchiolitis or, um, uh, Crone's disease, things like this that, which are very, very important, but are not covered here. So just, just be aware of that. Okay. So we'll crack on with the first MCQ question Lucas. Can you start? The, the poll are perfect. Thank you. So, um, I'll give you like a half a minute to answer that and then we'll check what people said. Okay, I think we can stop the pill. Now, actually, I think, because I think I'm able to do that. I just found the way to do that so I can do the polls on my own. Thank you. Okay. So most of you got the answer right? So it's answer e oral steroids and district with worsening advice. And the next question is quite similar. So before we discuss what that is and this disease in more detail, that's um let's try this question. Okay. So let's stop the pool now. So most of you guys got it right. So administered, administered nebulized adrenaline is the correct answer here. And let's discuss why. Um So probably most of you uh kind of thought of group when you read the questions. Uh So what I do think it's, it was group essentially uh the harsh inspiratory stridor or sound uh is kind of the key to this question and uh to figure out that this, this is croup and why it's worth kind of mentioning that uh the treatment of croup depends of the severity. So if a child comes in with mild group, which is some barking cough, but no stridor addressed, that's a very important discontinuation, then you just give them a one of those of steroids. Uh you usually give dexamethasone. But for example, I think in sick kids, they give oral predn. So it kind of, but I think they kind of varies by generally oral steroids for moderate and severe group. Uh you uh uh for moderate group, you give uh cortic oral corticosteroids as well. And for a severe group, uh you try, you can try nebulized adrenaline essentially. And, uh, with severe, moderate and severe group, well, with what the moderate group, it's important to kind of remember that you have the Stridor addressed. And that's the, for me, that was the key thing to remember how to distinguish between mild and moderate group that with moderate group, they're strider addressed. And with severe group, there are kind of signs that the child is kind of struggling with breathing and it's kind of getting tired because we've increased work of breathing. The Children kind of to start with, they try to cope with that and then they kind of slowly, slowly get, get tired. And uh you can kind of see that from the end of the bed and that will be the severe group and that in that case is you want to give nebulizer adrenaline uh and corticosteroid as well. Um Okay. So the next question, what is the most likely organism, a positive organism of this condition? And that's quite easy. So we'll give it like half a minute. Yeah. Okay. So it's parainfluenza parainfluenza virus. Most of you got it right. Uh So he will be um epiglottitis, uh para virus, strep pneumoniae because it's called range of uh uh condition infections. Uh Parma virus will be the um slapped cheek, uh disease and stuff. Aureus will be also a whole range of conditions. So parents, so group is parainfluenza virus and that's, that's definitely something we're remembering. Um Okay. Oh, there we go. I forget we had this stable uh hemophilias influenza in terms of strider. Uh the kind of if you have a child with strider, the most important differentials will be a group will be uh epiglottis, itis will be foreign body aspiration. Um There is also something called bacterial tracheitis, which can also cause group, which can also cause strider. Uh And from so essentially, when you have a childhood strider think of croup first. And then the next thing you would think of if the child looks much, looks very, very unwell will be epical otitis and epical otitis is is caused by haemophilus influenza. Uh strip pneumonia, otitis, media, pneumonia and manage itis. These are the key things that the skin infections and it can cause piper virus will be slapped cheek disease or fifth disease. Uh croup will be part influenza and stuff. Aureus will be skin infected, skin, essentially skin infections. Uh Okay. So this is just like a summary of how to manage group. Uh So um yeah, I think we we've covered, we've covered that a lot. We've, we've covered that before. So we want to go through that again. Oh, the only thing is um because sometimes you have these questions like when should you admit if you should admit the child to hospital? So think about admitting the child with group to hospital if they have moderate or severe group. To remember the distinction between mild and moderate that there is tried or addressed. So if the child has started address, then you want to consider admitting them to hospital. Also think about it if they're like less than six months old, if they have other kind of um upper airway abnormalities, for example, Laryngo Malaysia, which is kind of congenital flopper larynx, uh or if you're not sure what the diagnosis is. Um So uh the important differentials to think about in if you have a child with Strider, as we mentioned, this group is um epiglottitis, bacterial tracheitis, and also uh kind of this peritoneal insular obsesses and foreign body inhalation and the foreign body inhalation. I think I had a question about that either during my fifth year exam or finals and think about foreign body inhalation if there is a chat who was okay and was playing uh and then suddenly had this sudden onset strider. Uh And remember that I think the majority of the foreign body inhalations are kind of unwitnessed in a sense that parents actually have no idea when the child aspirated the the little items. So, so, so, so definitely if the parent kind of from the history is apparent that the parents didn't, didn't see the child inhaling or eating the little item, then don't rule out a foreign body inhalation immediately because it still might be it. Uh okay, the next question. Uh Okay. Um So most of you are gonna, right. So it's the right answer is subcostal recessions. So essentially all of the other um options or uh kind of signs of severe uh that the child is severely unwell and it's not managing uh with kind of with, with uh breathing essentially. Uh So definitely see. So breathing is, is a bad sign drilling. So, drilling is very characteristic of bacterial tracheitis, uh uh epiglottitis, sorry of epiglottitis. So when you have a very unwell child who can't swallow big uh and sitting in a so called tripled position. So kind of leaning forward and with their huh kind of our hands on your knees. And then think about epiglottitis. And drilling is a very kind of characteristic sign of that sign osis is obviously a very, very bad sign. Mean that the SATS are very, very low and reduced consciousness is essentially also very, very severe sign, which probably means that the child is not managing with, with breathing and needs needs intubation. And also a very important thing to mention is that if you suspect doctor uh epiglottis, itis do do not do an examination of the throat with a spatula because that may kind of exacerbate the swelling um and essentially close the airways of completely. So if you're suspecting, but uh epiglottitis, the most important thing is to get a senior anesthetist and to intubate the patient uh as soon as possible to secure the airway. And then you can think about federal management of the Oh, of that. Okay, let's move on. Uh This is just a nice picture of subcostal recessions, which is essentially just a sign of increased work of breathing, but it's not a critical sign. So if you see a child with subcostal recessions, it just means that they're struggling with, with breathing, but it's not a sign that they're like very, very unwell. Okay, next question. Um Okay. Um So yeah, that's actually quite a difficult question and I was struggling with this question as well, but the correct answer is that his brother has eczema. Uh and I think it's um so when you're doing like a history of a patient of a pediatric patient who may have asthma, it's always important to ask whether someone else in, if there's any family history of either asthma or eczema or hay fever. Because this tense teran, this kind of those three things tend are associated with each other and they tend to run in families. So here we have a topic triad. So eczema, asthma and hay fever and it's essentially a topic triad is a term that is used when a person has a combination of those three uh conditions. And very commonly people have just two of these. Uh So essentially, uh yeah, just worth remembering that's asked, my examined heavier are kind of quite closely correlated and they tend to run in families also when, for your Oskin key exams, it's worth because because sometimes asthma comes up, I think one of my friends had asked my, during their year five of skis and it's worth remembering like, what specific questions you should ask. So, uh, whether they have cough at night or early in the morning, um, whether, whether there is there are any pets at home, uh, whether there is any family history of any kind of asked my eczema or hay fever or whether the child has any allergies or eczema or anything like this. And also whether ever they also did the child ever have something called viral induced with. And if they did where they admitted to hospital or to intensive care unit. And um yeah, these are quite, these are important questions just to kind of help you with the history. Um uh Try to figure out what I sent the the cough for the child presents with. Uh okay. Uh Oh sorry, I I didn't change the, the title of this slide, but essentially this is how this slight nicely sums up how we diagnose asthma in people. So, um patient's who are more than 17 years old, they should have both spirometry with uh dilator reversibility testing and F and O test. So they should adults should have both Children age 5 to 16, they should have spyrometry in the first instances and the F F E N O test only if uh their spyrometry has is normal or if there is negative Broncodilator reversibility testing. And in Children less than five years, you make diagnose, you diagnose them with asthma based on clinical judgment. So this is just, and there is, with, when it comes to management of um Children, there is also clear distinction between Children, less than five and more than five years old. And we will come onto that in a second. Um Okay. So, yeah, that's the management uh ask my management questions. So let's correct it. Uh Cracking. Yeah. Okay. Uh So the most of you got to drive. So it's a, a trial of I see s uh uh this is, this is something to remember to learn by heart. Essentially. Uh There is always, um when I started for my finals, I was very confused whether I should in terms of ask my management, should I learn the nice guidelines or the PTS guidelines? Because there, there are some discrepancies between those two and essentially, uh I asked some people who sat there finals before and they said, said learn BTS guidelines and I think I learned them and um uh I think I didn't have any ask my questions, but most of people recommended learning the BTS guidelines. BTS guidelines for your exams. Uh So these are BTS guidelines for Children. And essentially, we're starting off with Beta two agonist uh as required. And then if we need uh to step up, we go for a very low, very low dose. I see s or we can go for uh leukotriene antagonist in Children who are less than five year, year, year years old. And, and as as I mentioned, there is a clear distinction between Children, less than five years old and more than five years old. So um so it's worth kind of remembering that. Okay. Uh Let's start with this question. Yeah. Okay. So it's physiological jaundice. Uh And with jaundice, uh the key thing to remember is there is a like depending when the jaundice starts, you will need to think about different causes. So we are very concerned about jaundice if it starts within the 1st 24 hours of life because it could be HBO incompatibility or more severely arrested incompatibility. Uh If it starts between 24 hours and it lasts till the baby is like two weeks old, then it's most commonly something benign like physiological jaundice. And with jaundice, which kind of lasts more than two weeks. Uh after the baby was born, we are very worried. Uh it needs to be investigated essentially because it could be uh biliary atresia, which which is essentially what we worry about in Children with prolonged jaundice. But very commonly breast fed babies can have prolonged jaundice. Uh For some, I think uh for some reason, breast with babies and premature babies are at higher risk of uh developing jaundice. And there is um something called breast feeding jaundice, which is essentially Children, babies who have jaundice for more than two weeks. And it's uncomplicated. Billy, Billy Ruben, which is raised. Uh So when the baby has had jaundice for more than two weeks, you, you do the whole work up, but the critical distinction is to check the bilirubin, the conjugated and unconjugated bilirubin because if it's conjugated bilirubin which is race, then you worry about biliary atresia and you need to refer the baby to the pediatrician insurgents and if the, if the bilirubin uh that is high, it's unconjugated, then it's most probably the uh breast feeding jaundice, jaundice of breast fed babies. Uh Okay. Uh Oh okay. Let's I think I already explained that question. But uh huh. Let's see if you, if you can get that, get this. Yes. So essentially we're worried if the John this lasts more than two weeks and certainly would be worried if the if John this lasted for more than three weeks in a term baby. Uh Okay. Uh Next question. Oh okay. So that's interesting. So the correct answer is reduced. Billary tree outflow, smaller woman of billary treat. Uh because essentially like physiologically, babies have raised and conjugated bilirubin. Uh If the baby had um obstructed Hillary tree outflow, then it would be a similar case to biliary atresia when you have increased when you have raised a conjugated bilirubin. So that's so uh d is the right answer. Um um I'm not sure if I explain it very well, but essentially, yeah, babies have uh faster red cell cell turnover uh and uh the enzymes that are in the liver, they don't have kind of great activity to start with. And they, and that and these enzymes are, which are responsible for conjugation, conjugation of Billy Ruben, they're not as active as they should be when the baby is born and they kind of become slowly more and more active. So, therefore, the babies are at risk of um having raised unconjugated bilirubin. And remember that unconjugated bilirubin is insoluble in water by soluble in lipids, which means it can cross blood uh blood brain barrier and cause kernicterus. So uh it wouldn't be the case in biliary atresia when we have increased conjugated bilirubin because conjugated bilirubin is not soluble in lipids. So it wouldn't cross the blood brain barrier with a biliary atresia. We are worried about the liver and we want to do a surgery quite quickly to avoid uh the need for a liver transplant later on in the baby's life. Uh I'm not sure if that makes sense, but if you do have any questions, then please put them in the chart. Um uh we can come back to it. Yeah, okay. So this nicely sums up what are the kind of main causes of neonatal jaundice. And as I said, there is a, you, you always think about the onset of the jaundice and depending on when it started, you would think about those differentials. Um the the kind of uh the most scary one is racist in compare compatibility. But it's quite rare now. Uh because with Reese's incompatibility, the baby is at very high risk of uh kernicterus, which is which can lead to cerebral palsy. Uh and kind of basically the in races incompatibility, the un conjugated bilirubin levels can get so high that it cross, they cross the blood brain barrier and the bilirubin is deposited in the brain in the basal ganglia and in the brainstem nuclei. And that can have basically that can lead to a type of cerebral policy. So it basically can cause reblood policy. Uh some learning difficulties and also uh sensorineural hearing clause. So, so when the, so yeah, so that's the most serious one. Uh but it's very releasing now, uh the other causes which you should think of is uh glucose, six phosphate deficiency. And I think also you should know this disease from hematology, but it's essentially uh congenital disease and essentially most of people who have this disease, they're fine. But then they can get joined this when they eat some specific food or have some uh medications such as Datsun or some malaria, malaria medications. Uh And uh yeah, and it's common indicate of people who come from like Mediterranean area, Middle East and far East or Africa Gilbert syndrome. So yeah, probably remember from G eye from last year, but we think about Gilbert syndrome when we have isolated kind of phrase in Billy Ruben Kriegel. Not, I'm not sure if I can pronounce this, but this syndrome. Uh actually, it's very, very rare. This, this very rarely comes up. Oh, that's the kind of autism away. Uh I think uh autosomal recessive disorder also congenital uh in which you have uh kind of absent or defective enzyme and deliver which responsible for congregation of ribbon. And you can have unconjugated bilirubin mia uh with this syndrome and then always think of sepsis, congenital infection in bruising as well. Uh bruising. Well, when people, when babies are born, like when they have assisted uh delivery with forceps of uh for example, with forceps and think they can have like the swelling's and bruises on their head. And if they do have it, then they're also at increased risk of jaundice because any bruising in a baby increases the risk of jaundice. Then John, this which starts between two and 14 days. It's most commonly uh physiological. And as I said, it's more, more common in breast premature babies. Uh And if John this uh kind of uh kind of start or prolongs after the baby is turns two weeks, then we are very worried about Hillary A Tricia and we should check conjugated versus and conjugated bilirubin. Uh uh Yeah, there are other other causes as well. Uh So with biliary atresia, we have the absent biotech which essentially causes a backup of conjugated bilirubin in deliver and may lead to liver cirrhosis. So if we don't intervene on time. Uh It can be that the baby may end up needing a liver transplant and the treatment is with Kasai procedure. So we need to refer, refer the baby to the surgeons. Essentially with photo, we have jaundice, we treated either with uh phototherapy, light, light, phototherapy. So I'm not sure if you've seen babies on your placements who they were like like lying and they, there were some blue light uh used. Uh So that's how you treat photo. Uh That's how you treat join this or if you're very worried. Um And the bilirubin levels are sky high. You use exchange transfusion in severe cases and this is to prevent the kernicterus and the risk of encephalopathy. Uh oh, and this is, I think that's quite useful to remember while are what, what investigations you should do as a part of your jaundice screen. Uh Okay. Uh And this is just how you measure with the routine essentially. Um You can use it trans use can measure it transfer transcutaneous lee and you can take silver medals. Uh Okay. Uh Let's start the next question. Okay. Um So the correct answer is see, BP, I'm actually struggling uh struggling to, to struggled with that question as well. Uh But I guess like in a child who has a big mass in your abdomen, you worry about Wilms tumor. Uh But I actually have, I was struggling to find answer, find an answer to why BP is the correct answer in this question. So essentially, I don't know, but I think, I think that this question was getting at the fact that this will be, you should be suspicious of Wilms tumor. Uh Sorry, that's quite deliberate, not, not a great explanation, but I, I really struggled with this question. Uh Okay. Next Guan, so the same patient. Okay. Um So the correct answer is a lung and it's kind of one of those questions which either, you know, or you don't know the answer to. Uh So once, well, Stuart tends to metastasize to lungs. Uh okay. Next one. Okay. So that's, that was quite straightforward. So that would be social worker, uh sorry, a safeguarding officer who you should involve. So we are worried about uh child abuse in this question. And I think uh like that's a very important topic for your exams just to kind of know what your the types of uh child abuse risk factors and also how to recognize uh recognize it. So like physical abuse, uh remember that for example, a torn frenulum is a kind of uh kind of it should make you very suspicious that something is not right? Uh And it's just from like the parent pushing the bottle into the baby's mouth, you can turn the frenulum and it's quite, it's very, very suspicious. Uh Also like um any bite marks or like patterned burns, such as for example, like burns from cigarettes or glove and stocking pattern when the baby was kind of put into some very, very hot water and there are burns on their hands and their feet. Uh And also like also thinking about the age of the child. So we're physical abuse, like we would be very suspicious if a non mobile child had a bruise. Uh but like obviously they can't move. So how can they get a bruise? Uh and also like location of like essentially also any fractures. So the location uh fractures is also important through of any fracture, drips, uh metaphyseal oh fractures or fractures of the skull. Should you make very suspicious? Uh And also kind of if they're like at multiple stages of healing. Uh And if there is like any delay in presentation, you should also think about physical abuse, uh uh especially uh like with ribs, the the fractures of the posterior part of the ribs should make you very, very suspicious that something is not right? And with, okay, I think uh the second, the next question we'll touch on uh child abuse as well. So let's deal with the next one. Okay. So, yeah, so most of you guys got it right. So parents who miss the first follow up appointment. So we've neglect. That's another type of child abuse. We think about this when you look at the child and like the child has dirty clothes or is inappropriately dressed for the weather or um has faltering growth or has to vote some developmental delay or pull dental hygiene uh or any kind of sort of untreated medical problems also pull school attendance is, is kind of quite suspicious uh failure to attend medical appointments. Uh And also kind of just by looking at the child, you can, you can kind of suspected when the child is kind of withdrawn, watchful or have, has some self abusive behaviors. Uh So yeah, essentially if neglect in this case, it will be uh well, um all of those except for parents who missed the first full of appointment because we would would be worried about neglect. Parents missed the appointments several, several occasions just if they missed it once, then that's not a cause for concern, but all of the other options will be will be will be quite concerning. Uh okay and the next question, okay. So at this still, sorry for my spelling distal radius would be uh would be uh would be the correct answer here. Uh All of the others will be quite concerning. Well, I wouldn't be so much like it wouldn't be, I would be maybe slightly concerned with the fractured femur, uh fractured skull steered um of posterial rip will be definitely quite concerned because it's quite difficult to kind of rate, kind of fact sustain a fracture just by having like some sort of trauma uh just from kind of playing the ball with other appears. So, but this uh so so, but this delivery just, I think it's quite a common place for Children to have to have a fracture. Uh, so, so, so that will be the correct answer here. Um, okay. Uh, so, uh, just quickly, uh, nonaccidental injury is also quite a very, it's very important topic and I think we, we, we've discussed, um, a lot of a already but injury in a child who can't move but essentially can't, can't walk or can't crawl is quite suspicious. But, oh, that's important point when the history and the injury, our income consistent or when you ask both the mom and the dad and their histories are kind of inconsistent, that's also quite worrying delay in seeking medical attention, multiple fractures, retinal hemorrhage. So there is a thing called shaken baby syndrome. Uh, and retinol you can get retinal hemorrhages just from like taking the baby if you're like. And that will be part kind of one of the features of that syndrome, turn frenulum would be very, very concerning, uh, and uh, history of household flaws resulting in fractures. Yeah. And this kind of sides fracture size which, uh, which will be suspicious or just worth remembering, uh, especially like fractures which are of different ages and fractures in a non mobile child would be very, very suspicious. Um, okay. Okay. Next question. That's okay. Okay. So the correct answer is BP. And I think what that question is getting at is that, um, socially Children can compensate uh for like uh very, very long in terms of BP until they're very, very unwell. So if a child has hypertension, uh that means that they're very, very unwell and they are, they are, you need to call a senior immediately. Uh So with the BP to Children maintain their BP, even if they're have like sepsis, they can maintain that quite for a long period of time and they only drop it when um when there is very, when they're very, very unwell. Um Okay, next question. Um okay, so let's stop the pull. So, so most of you got it wrong. So the urine output is not a part of the pediatric sex is sex, but adrenaline is because you would consider Iowa traffic support in Children quite early on if they Yeah, uh if they're like shocked. Uh So you in terms of like sepsis six. So it's quite, quite, it's different to what we do with adults. Uh and you measure, you take blood cultures, you take blood glucose which you don't normally do. Uh the adults and you take lactate and you give antibiotics, high flu oxygen and you consider I have the fluid resuscitation if they're shocked and you would also consider other tropic uh support and senior escalation to a senior. Okay. Uh Now we have some questions about child development. Uh So uh huh. Okay. So more most of you got it right? So it's 12 months. Uh And again, it's one of those scratches which you either now the answer to or you don't know. Uh Okay. Uh So let's deal with the next one and we'll discuss um uh speech development in a second. So let's start. Yeah. So it's three years and essentially with, with kind of developed child development, you, you need to kind of think both about the, obviously, there are like four domains of development. You have uh gross motor, fine motor, uh kind of speech and hearing and also the kind of social and emotional development of a child. And they're um different kind of skills and different times when a child should acquire them with each kind of domain. I would think like there is you should, I think these are in this, for example, here are median median ages. So uh on average three month old baby will be able to turn their head towards the sound, for example, and uh you can also think about the age is when you should be worried. So for example, with walking, if uh the threshold is 18 months, so if an 18 month old baby doesn't walk, you should have been worried and the median age for walking is 12 months. So there is quite a discrepancy between the media and the cut off months. A cut off a age is when the child do something and it's just where bearing in mind. Uh So here we have some speech development milestones. And these are the main median age is uh obviously media means that like some babies will acquire the skill a little bit earlier on, some babies will acquire the skills a little bit later on because each child develops at its own pace, essentially. Uh but there are some set times after which when the child doesn't do a certain thing that we should be worried, for example, with walking or we're sitting. Uh I think the median age for sitting is nine months, but the the child should be able to sit on their own by the age of 12 months. If they don't, then you should be worried that something is not right. Uh Yeah. And essentially so uh with a six month old baby, you, they will do double syllabus and with the nine month old baby, they will said they, they will be able to say mama or dada uh at 12 month old baby will be able to respond to their own name. And uh 15 months old baby will kind of understand like simple commands. A 2.5 year old baby. Uh Dubler, I should say uh they will have, they will start building ash kind of sentences like like two word sentences and they'll have, they'll, they'll know around 200 words and the free years old baby will be child baby. Uh they will be, they will talk and short sentences and here are some motor development milestones. Uh And these are the median age is when the child should be able to uh to acquire a given skill. Uh um And in terms of um development, so here are some red flags. I thought this slide was quite useful. And uh because because sometimes uh you have questions, which kind of the main point is to pick up that there is some delay into if the babies in the baby's development. And I think that that a slide is quite useful and kind of some, it nicely sums up when you should be worried. Uh Okay. Okay. Now we get, we're getting to some infectious disease stuff. So let's, let's start with the first question from this topic. Yeah. Okay. Uh So that was actually quite tricky question, but the correct answer is since in your old deafness, that's uh that's so essentially, do you guys know what that is? Can someone put in the chat? What, what that is? Do we know what disease that is? Yeah, that's measles. Thank you. So that's measles. And uh the thing that we can see in the photo are Koplik spots. So these are these white uh kind of spots on the kind of inner side of your chick, uh the mucosal membrane. And uh essentially uh it's very important to know the complications of measles for some reason they come up. Um and questions quite often. Uh So the most kind of common complication of measles is otitis media, but other complications include pneumonia and Katha litis and uh diarrhea as well. So the only kind of thing that is not a complication of measles is sensing your oldest deafness. Uh Okay. So next question, this one is quite, it's quite hard. Yeah. Yeah. Okay. So most of you guys got it right. So that's answer the sub acute sclerosing. Pandan Catholic, Pandan, Katha litis. And it's essentially, it's quite rare And I think other than that, other than knowing that this is a right complication of measles. You don't need to know much about this condition and it can present 5 to 10 years after your initial infection. Uh And all of the other complications which we mentioned are like more immediate in the sense that they kind of uh happen close to the initial infection. Okay, next question. Okay. Sorry, I've got some slides. So um let's post the pole for a second. Um So about measles. So these are the complication of measles. As I mentioned, there's also keratotic conjunctive itis, uh Cornell's ulceration and you can also get diarrhea and myocarditis and they, they're worf remembering because they do come up in MCQ is quite often. Um Okay, I don't know what happened with that slide, but it's got some how moved a little bit down, but I think you can still see the images. So let's uh no, uh I don't know how to restart that pole, but sorry, I, I don't know how to restore that focus already started it and I stopped it, but essentially, um, that is, uh, the hand mouth and food disease and it's caused by Coxsackie virus. And the next question I think is about full exclusion. And so let's do this one. Yeah. Okay. So, quite varied responses. But I think most of you got it right. So the child can go back to school when he feels well, So there is no need to kind of isolate the child and well, well, with school exclusion, it's very important to learn all of those. Um uh all the diseases that commonly come up come up are like chicken pox measles, mumps, rubella, scarlet fever, pertussis, or whooping cough, hand foot and mouth disease, uh um impetigo as well. So very, very important to not learn all of that because that really comes up very, very often in exams. Um But with hand foot and mouth disease, there is no need to uh to uh isolated child from school. And essentially um it kind of presents with blisters on hand, foot and mouth. Uh and it's self limiting. So you treat it symptomatically. So you get just general advice and hydration in a little juicy a and very, very important to remember that Children don't need to be excluded from school from school. Uh Okay. Ex question. Yeah. Spot on everyone I think. Got it right. So uh the child can return to school when the spots are scabbed over and that's, that's only the case for chicken pox. Uh and question about the complications of chicken fogs. Okay. Uh So essentially, um the correct answer is dilated cardiomyopathy. So essentially all of the other kind of options are potential complications of versa or sir virus infection. So, pneumonia uh like it can be a complication very commonly. You could get secondary bacterial infection because the rushes j and you scratch it. So it can get easily infected. You can have some CNS involvement as well, which can lead to kind of cerebral ataxia uh or uh kind of generalized Katha litis or a septic meningitis as well. And Ramsey hand symptom hand symptom syndrome is very, very is a well known complication of uh very serious ulcer virus infection. So the only one which is not a styletted cardiomyopathy. Um Okay. So just a couple of words about chicken pox. So I think uh the most important thing is that that that's present with fever and thrash rash is itchy and it's carrying and it's very, very contagious and it spreads by respiratory droplets. Uh and uh it can be treated with acyclovir in some instances. Uh and generally pregnant women should be careful. So uh if, if, if a woman had chicken pox in the past, then that's fine. But if anyone didn't have any chicken pox in the past, then she should be very um cautious with any context with potential Children who may have to get box because, uh, you can get, get quite severe of complications if you get chicken pox uh during pregnancy. Uh, and I think there are, uh you can get give I D I G to a pregnant woman who didn't have chicken pox in the past but was exposed to a person to an infectious person. But I think that's more of an option guide subject, not piece pediatric subject. Uh Yeah. And like, and then when you get older, you can get shingles. Uh and shingles is essentially just kind of presents with rush in a kind of dermatological distribution and it could be very, very painful and then uh you could have some uh neurologic pain afterwards. Uh okay. Uh uh shingles, he also treat with acyclovir. Okay. Uh Next question. Uh Yeah. So most of you got right. So dry the neonate and remove any wet towels. So that's the first thing you do. You just kind of dry the baby because we don't want the baby to get hypothermic because it's very bad. And I think there is some evidence saying that hypothermic noon aids have generally good worse outcomes. And uh we, we want, while drying the baby with the table, we want to want to, we also want to stimulate them slightly. Uh And that's the the the first thing you would you would do. And these resuscitation guidelines, there are very, very important to know for kind of em sick use knowledge, test purpose. Uh So you drive the baby first when you get the baby and you kind of remove the wet towels and cover them with a fresh one and you assess the tone color breathing and heart rate of the baby. And if the baby is not breathing or if it's gasping, so you give five inflation breaths and the inflation breaths are different from ventilation breaths, which you normally do because the aim of uh inflation breath is to kind of open the lines because remember the baby was just born. So their, their lands need to inflate for the first time. And uh when you're like giving the inflation breaths and the chest isn't moving, then you want to kind of recheck the head position and consider any airways maneuvers to kind of and then repeat the inflation breaths to check if the chest is moving. Because if the chest is moving, then that means that your inflation breaths are not very effective. And then you check the heart rate. And that's very important to remember that if the heart rate is not detectable or it's less than 60 you start chest compressions and the ratio is free compressions to one breath and we recheck every recheck the heartrate every 30 seconds. That's essentially what you need to know her yet. The exam. Okay. Well, which of the following is not part of Apgar score. Uh start the question. Okay. So uh it's respirator it and uh that is not part of Apgar score and this is uh how we score it. And essentially Apgar can stand for a can stand for appearance. So basically the color of the baby. So if it's pink, then you get to if they kind of the pink, the kind of torso is pig, but the limbs are blue, you with one. And if the baby is like blue, blue all over that give zero, then P can stent puffer polls and then G can stand for grimace. So essentially, uh if the baby kind of cry senses her coughs after the baby was born or if there is crewman's on the baby's face, uh and then uh make sense. Second, a stands for activities. So if they're like crying and moving their whims or if they cry is quite a uh sorry activity, active woman here, if the baby is kind of moving their limbs or if it's only fixing the limbs, or if it's if the baby is like totally floppy and then r stands for respiratory effort, not great as respiratory effort. So if the, if there is like a good respirator, good breaths, the baby is crying or if there are breaths are quite irregular and week or if the baby's not moving at all. So essentially, I think it's quite useful to remember. The essentially up guard can stand for like all of these categories. Think the letters can help you with remembering all those categories and how is correct its current. Okay, next question. Yeah. So ultrasound will be the investigation of choice in this case. And the next question is about what's the most likely diagnosis in this case? Yeah, and it's interception. Exactly. Uh And the next question, what is the management? Yeah. So it's uh so it's our enema that you do. Uh And the next one, which options are true. Oh, it's obviously Sara in the, in the um multiple choice questions from uh in the, in the answers, obviously, obviously, it's typically occurs between 18 and 24 months, not 224. And the uh enema is the correct answer. Although I'm slightly confused by this question because I think Pass Met says, yeah, exactly. Pass Met says are insufflation is the treatment of soul choice. And I actually not sure what I kind of, I came across both options like either said R N M A R R. Insufflation, I think Pass Met says Oren sufflation. So I'm actually not sure what is the difference? Uh I'm slightly confused by it. Uh But I think like I usually go for what Pass Met says actually. So um oh, there is the same thing. Okay. Yeah. So essentially they were both, both answers were correct. Um Are in sufflation are enema uh okay. And the question uh well, are we with the question? Yeah. So it's more common in boys. That's, that's the correct uh, answer. And, yeah, again, it's what essentially one of these, these questions, whether, you know, uh, this or you don't. And it's hard to, hard to arrive at the answer at the correct answer. Um, if you don't know. Uh, so just a couple of, uh, just quickly let's go through interception. So, uh, it's worth, uh, it's kind of, uh, I think the most important thing about this, it is that it knucklers in quite young Children, most of them are under two years old. Uh And they have this kind of classic colicky pain because the Bible kind of gets semi abstracted and you get this kind of Paracelsus uh because the Bible is kind of trying to push the bowel contents through. Uh and you get this colicky bouts of pain and you get vomiting as well. And the class, the child classically grows news to the chest and you get the red current jelly stool, which is essentially kind of bloody mucus in the stool that gives the gives the stool disappearance of appearance of red current. And on the polyp patient like clinically on probation of the abdomen, you will feel kind of sausage shaped mass where the affected segment of the balance is. Uh and the investigation you investigated with ultrasound looking for something which is called target sign, not sure like uh like how it actually looks on ultrasound and the treatment is with IV fluids. Uh because obviously probably the child will be quite dehydrated, dehydrated from all the vomiting and our enema in the first instants. And if not, then you, if that fails, then year ago for surgery. Uh, okay. Uh, next question. Yeah. Yeah. So that was quite easy. Pyloric stenosis. Uh, and the next question is, what is the treatment, which I think is a little bit more tricky. Yeah. And it's Ranch. That Pie Loro myotomy. That's the treatment for that, That that's the treatment of choice and next question. Okay. Okay. Mhm. Yeah. So the correct answer is hypokalemic, hypokalemic metabolic alkalosis iss and the reason for that is that the child is vomiting. So obviously we have chloric acid in our stomach. So when the child is vomiting, they're getting rid of the uh the hydrogen ions which is essentially getting rid of acid. So therefore they are alka lot ick and why they have low potassium. Uh As far as I remember that has to do with the ion transporters in the stomach cells. So I think for each uh hydrogen island that is transported into the parietal cells which make the stomach uh stomach acid. Uh one for each. No, that's the there's something to do with I am transport. Uh I don't remember exactly what that was, but it means that if we, if we're getting uh if we're like removing, removing uh uh stomach acid because the baby is vomiting, we will, the child will be short of both hydrogen ions and potassium. Uh and that's why the child will be alka lot ick and will be also uh low in chloride and potassium. Uh okay. And so few worries about pyloric stenosis. So it's the, it's quite straightforward presentation. So it's kind of uh projectile vomiting, which is non violence and it tends to present uh 2 to 8 weeks when the baby is 2 to 8 weeks old and the majority of affected babies are male and can lead to quite significant dehydration and weight plus. And when it comes to investigation, we can do a test feed. And when you do a test feed, the sometimes you can observe like a parastatal tick movements. Uh like when you're looking at the abdomen, you can kind of see where because the kind of the bowel uh the stomach is kind of strike to push the contents through that stenosis stenotic part. Uh But kind of, I think the uh of investigation of choice would be an ultrasound and you treated with Ramstad uh pill, oral myotomy uh and also on palpitation of the abdomen. You can classically feel like olive shaped mass in the right upper quadrant. Uh the child will have faltering growth uh and kind of will also seem quite hungry after each feet. Uh Okay, next question. Yeah. So most of you got it right. So that will be here spring disease and that's because um of kind of this bowel segment. Uh So here's from disease. Uh Well, it commonly presents with failure to pass me Konya um because usually baby should pass meconium within the 1st 24 hours of life. And uh and definitely within the 1st 48 hours. Uh So if the baby doesn't pass the con um within that time frame, then we should think about here spring disease. And it could be also one of the potential causes of constipation in older Children. And also very important to remember is that is strongly associated with Down Syndrome and males are more commonly affected than females. And it's to do to do with lack kind of iconic iconic segment of the bowel. So essentially bowel doesn't have any parasympathetic uh innovation. So there are no just a part of part one segment of the bowel doesn't have parasympathetic innovation. So there is no personal says there there is no movement of the stool. Uh so investigation. So it's like, well you would probably do and I'm not sure if you would do theory uh in in a child because like in Children, we very rarely do theory unless we really have to. But you do full thickness rectal biopsy. And that's very, very important uh to remember. And uh well, the treatment like initially you that like you go, you give the child IV fluids and you also do rectal wash out and it's a the kind of definite treatment is surgery. So basically cutting out the affected part of the bowel and an estimate using the healthy bowel to the anus. Uh, okay. Next question. Yeah, that's toddler's diarrhea. Exactly. Uh, so typically affects Children age 6, 30 months. And, uh, kind of the classic presentation is that you have multiple bowel movements and you have undigested food. Uh, and that's the key word to remember. So, in any question that, that, that gets a toddler's diarrhea, you would have the word and they just did food, uh and the growth will be normal. So it's not affecting uh the child, the child's growth and there would, there would the child will also gain weight normally uh to investigate. Well, you, you should rule out any potential invest uh effective causes and essentially with treatment. Uh you, it's essentially kind of supportive. It should go away on its own, I would say, uh and you can get some lifestyle advice as well, but I think I very rarely came across questions. I'm not sure if I ever came across, come across any question on toddler's diarrhea, which is, which was asking about management. Most of it is just the child has diarrhea. What is it? And if you have undigested food in a toddler in the stool of a in toddler, still, then think about toddler syria. Okay. Next question. Okay. Um Okay. Uh So I'm a little bit puzzled by this question uh because um I was hesitating between uh B and D, I can see that most of you chose answer D uh in terms. So, so let's discuss the treatment of DKA first. So, first of all, you escalate to this to a senior cause that's a medical emergency. And with IV fluids, you should be very careful with IV fluids. And it's worth remembering that um the, the, the, the balance that you give, it's 10 mils per kilogram of uh 100.9 sodium chloride because usually like uh when you give uh fluid belo's two Children as 20 mils per kilogram. But in DKA, you give 10 and it's quite uh and you should discuss um who the senior if you want to give any feather IV fluids. Uh and you start insulin infusion 1 to 2 hours after starting IV fluids. So not straight away. And I think very important to remember is that you continue the any long acting insulin that the child is on but you stop short acting insulin. Uh And uh well, I'm quite puzzled by this question because or is it uh because one of the options said uh with IV bowlers based on the child's weight and that's not completely true because you should give bowlers like you should give IV bolus, but it should be 10 mils per kilogram. So it would be a standard IV fluid bolus because the standard is 20 mils per kilogram. But on the other hand, like the, the question, the correct answer as per slice that I was given uh as 0.9 sodium chloride plus 40 minimal of um potassium chloride, insulin. Uh yeah, with without insulin infusion. Uh So just so it will be option. Sorry, I think the correct uh will be option. E uh and you, I'm not sure because, because it doesn't give uh any clue as to how much you should, how much fluid you should give it just, just type of fluid you should give plus you should give potassium chloride. And uh as far as I, as I know, um nice guidelines say that you should give potassium chloride only. You should give potassium chloride. You should add it to all IV fluids except IV Bullis is um so, so I'm quite puzzled by this question, but essentially I think we should stick to what we have on this slide, which is you start the escalate it to your senior is type IV fluids first and the rate is important because it's 10 mils per kilogram of sodium chloride. Uh And you add both, ask you clara to any other fluids that you give. But before you do, you should discuss it with a senior and then you add uh and then you start insulin a few infusion 1 to 2 hours after uh starting IV fluids. Okay. Hope that makes sense. Uh And then the next question. Yeah. So quite mixed answers here in this question. Uh But the correct answer like the correct answer, which is not part of the diabetes sick day rules are, is um, option a increased fluid intake, high sugar drinks, local nasal are recommended. So, uh, I think that's incorrect because they're recommending high sugar drinks. Whereas like part part of uh celebrity Six Days rules is that you should drink plenty of water, but they're not recommending uh, any high sugar drinks and all of the, all of the remaining options are, are correct. Uh, okay. So, um, just I thought we could, we can go through some of the, some of the pediatric fluid prescribing because that's quite important. And uh for me, it also came up on my P C A. Uh So it's worth kind of knowing the basic stuff. Uh So as you probably know, we have three types of IV fluids. Uh So we have resuscitation, replacement fluids and maintenance fluids and we're resuscitation, we give IV fluid bolus and it's usually 20 mils per kilogram unless the the child is and struck has DKA or heart failure. In that case, we can, we want to give 10 mils per kilogram when it comes to replacement fluids. Um Well, we need to calculate the percentage like of dehydration. So it's not like it sounds quite complicated but it isn't. If the child is like slightly dehydrated, you say, okay. Well, we'll say it's 5% dehydration and you use it to calculate how much fluid you should give. And uh if the child is like super super dehydrated uh then you, you take 10% dehydration uh and you put it here in the equation and you, it gives you how much of IV fluids you should give uh to the child as replacement fluids. And I said it's important to remember that you replace it over 48 hours. So the volume of fluid that you've got, you get from this equation, you, you divided by two and um and you, you try, you should basically try to push the fluids into the child over 48 hours. And we normally use 480.9 sodium chloride with potassium as our replacement fluids. In maintenance, maintenance fluids are different to what we use in adults. So we use 0.9 sodium chloride with 5% glucose. That's our maintenance fluid uh of toys and uh well, calculating how much should give is quite tricky because you need to remember that for the 1st 100 mills uh for the 1st 10 kg, you give 100 mils per kilo per day. Then for the next 10 kg. So when the child is like what the child's weight is, I don't know, 15, you would give them a liter and then uh 50 mil mills times five, which will be 250 mills. Uh So essentially you give 50 mils per kilo per day for the next 10 kg and then over 20 kg, uh we give 20 mils per killer per day, but we don't want to give too much. So uh for a period of 24 hours, we don't want to exceed uh 2.5 liters in boys and two liters in girls. So we don't want to give more than that. And we here are some sodium requirements which like roughly you can try remembering. And again, it depends whether, whether that's the 1st 10 kg, 2nd 10 killer or over 20 kg. And uh I think it's, it's worth remembering because um as I said, I had a question like this on my P S A and I had to use um I needed to remember how much potassium to give as a maintenance fluids, fluids, how much potassium to give in maintenance fluids to a child. Uh Okay. Uh We've, we've dealt with that question. Uh So let's go to the next one. Oh um And I just saw your question. So how to find dehydration percent. Uh So essentially, if the child is not dehydrated, they're like 0% dehydrated. Then if the child is like slightly dehydrated, you get, you take 5% as your dehydration percent. And if the child is like very severely dehydrated, so they have like greatest skin turgor. Uh they have like increased heart trade, dry mucous membranes and you're like looking quite, quite dehydrated, like from clinical examination point of view, then you take 10% as your dehydrate as your dehydration percent. And then you put that in the, as put that in the equation and you calculate how much fluid you should give and you then give it over 2048 hours. Okay. So that question uh mhm. Okay. Um So actually most of you went for answer A but the correct answer is B so uh well, let's do one more question and then we'll um we'll talk about February compunctions and uh okay deal with them. But let's do one more question about February compulsions and little little discuss that in more detail. Okay. Um So the correct answer is the discuss optimal hygiene measures and ensure vaccinations are up to date. So I can see that the majority of you went for a regular giving regular per suitable. But I think that's one of the, that's one of very common mistakes that people make. They kind of assume that if you give regular per suitable, then the child won't have very high fever and they won't have a favorite convulsion. But interestingly, research, like some research from what we know from research, uh there are giving regular procedural, doesn't um decrease, doesn't uh kind of decrease your chance of uh getting a february convulsion. So essentially you should tell the parents to give the child paracetamol when they have fever, but you shouldn't encourage them to give person, give the child paracetamol kind of to minimize the risk of february convulsions. So if the child doesn't have fever or um is unwell but doesn't have fever or has slight fever but not very high. Then you shouldn't encourage parents to give personable just for the sake of minimizing the risk of federal convulsion. Because as a, from what we know from research, it doesn't have like regular paracetamol doesn't decrease the risk of febrile convulsion. But the child should definitely have paracetamol if they're feeling unwell and they have quite high fever. Hope that makes sense. Uh, uh. Mhm. So, uh, and uh the optimal hygiene measures and vaccinations ensuring that vaccinations are up to date is important because we have Children get federal seizures when they are unwell and they have some sort of infection, most commonly viral infection and essentially federal seizures are caused by rapid increases in temperature and that's, that's the main trigger. So, and if, if we are like making sure like eliminating any potential sources of infection and making, making sure that the child is not exposed to a lot of bugs, essentially decreases the risk of any sort of infection, which increases the risk of uh other uh february convulsions. Um So it's quite common in Children. There are quite common in Children between six months and five years and they don't require federal investigation. However, uh Children who have had their first seizure or commonly admitted to hospital. Uh and it's important to remember what type of advice, what, what advice you should give to the parents. So, advise them to stay with the child and put them in a safe position and remember to tell them not to put anything in your mouth and uh tell them that they should call an ambulance if their seizure lasts more than five minutes. Because asked for a new definition of status epilepticus. If a seizure lasts more leste's more than five minutes, then it's called status epilepticus and it requires treatment. Uh uh and um mm once a third of patients of patient's who had a febrile convulsion will have another episode at some point. Uh Okay. Uh And speaking of status epilepticus, we've got our next next question. Okay. Yeah. Oh Violet. So I just saw your question. Uh So, well, essentially most of uh otitis media infections are viral and uh you should not jump to prescribing antibiotics if you have, if the child has um otitis media. Uh But I think there are some, as far as I remember, there are some kind of strict situations when you should prescribe antibiotics. Uh But most of the otitis media are viral and most um uh and most um and very commonly, the obviously february convulsions can also occur in a bacterial infection because like the main mechanism they're triggered by very quick raises in the child's temperature. That's the main trigger. But for some, I think because most of the infections and Children are viral, you get the more commonly with viral infections, but you obviously can get them with bacterial infections as well. Uh And with why was it more likely to be viral because most of the viral, most of the ear infections are viral. Most of otitis media are viral in. And uh, yeah, I hope that answers that question and I'm not sure. Uh I mean, I can try to arrange, uh, it's somehow so you can get the slides, not sure how to do it, but I'll ask and I'll try to send them to you if, if you're keen. Um okay. Um where is the pole? So let's see what? Yeah, so majority of you got, right. So, rectal diazePAM would be the treatment of toys. Although it's quite weird because, well, rectal diazePAM or, or bookal Midazolam, they're used in the community as a treatment of uh status epilepticus. And in hospital we more commonly that they use IV LORazepam. But I'm assuming that the correct option is uh Rectal diazePAM because the child probably doesn't have IV access. So they will go for a rectal diazePAM and try to insert the cannula in the meantime, that's my understanding. But essentially uh uh is that, do we have another question of status? Know that that was it? Okay. So let's talk about status epilepticus or more about the management of status epilepticus. So, um it's status epilepticus is defined as any seizure activity which lasts more than five minutes. And you should like, you should always tell the parents like if you're diagnosing a child with, with epilepsy or a child had a febrile seizure. Always tell the parents in an Oscar situation that you should call for an ambulance. If the child has been seizing for more than five minutes. And uh in the community, you give Bukom Midazolam or rectal diazePAM and the hospital said thank you, give me LORazepam uh and step too. So you recheck after five minutes after the first Benzo. If this child is still uh seizing, then you repeat Benzos again, then if the child is still seizing after the second Benzo, you give uh levetiracetam IV. And then if the child is still seizing you live Penneteau in IV. And after that point, you obviously, you would probably call forcing your help earlier on. But kind of definite management. If nothing helps, you need to use propofol and kind of intubate the patient and uh induce general anesthesia because that's the only thing essentially left to do. So, quite important to know where are the kind of steps of management of status epilepticus. Uh And I think it's slightly different in adults. Uh I took it from kind of Scottish guidelines but kind of uh I assume it's kind of uh in keeping with what the kind of national guidelines say. Okay. Uh Okay, next question. Okay. So let's quickly discuss this one. So there are some split in the answers, but that's cyanotic breath holding spell. That's the correct answer. And many people went for a reflects anoxic seizure cause they're quite similar and I can see why some people chose that option, but that's cyanotic breath holding spells and let me discuss why in this slide. So cyanotic breath holding spells is essentially when the child kind of gets really upset and it's trying. Um and then at, at some point, they kind of stop breathing and they kind of lose consciousness go floppy and then they come back. So that's when the child is upset and is crying. And your reflexe anoxic seizure is when the child is started, when it's surprised or scared by something. And then the child goes pale loses consciousness and may have some kind of tonic clonic activity and then it comes back again. And in this, um in Children, in whom we suspect reflex anoxic seizures, we should also check E C G uh to check the QT interval because um just to be on uh check if it's not prolonged essentially. Uh because there could be kind of potentially a cardiac cause to this presentation. Uh So the kind of main difference between those two is that in cyanotic breath holding, suppose the child is upset and crying and when reflects anoxic seizure, the child is scared, like started about something. And, and that's, that's the main difference, but they're like both nine and they tend to go away at some point when the as the child kind of uh gets older. Okay, I think, well, it's past eight o'clock now. So just there are just a couple of questions we didn't go through, but we'll try to get you the slides. So if you can have a look at them, but I just want to go through the eggs and tips. Uh So these are like the very important topics which you should remember to cover like bronchiolitis. A lot of like also like some other gi stuff like Michael's diverticulum, appendicitis, necrotizing uh the neck. Also bronchiolitis size cystic fibrosis, constipation, meningitis, things like encapsulitis as well. Also other kind of infectious diseases like scarlet fever, uh mumps, rubella, we talked about measles, whooping cough. So, so lots of stuff and also like rashes, they're, they're also quite, quite common and zero to finals. Yeah, I agree. Zero to finals are, are great. And I also, I also used a lot uh obviously pass med but also for my um Os Keys. Um I used a lot, Yassky Stop. It's quite good. Uh uh They have also like there is a book which you can buy, but I actually, I don't think the book is worth paying so much money because most of the resources are available online. Uh And uh I think Kiki Matics also have some Oscal stations which are kind of worth looking at. Obviously, you have to pay for them. But if you're worried about your skis, uh then that's certainly a good thing to practice with. And uh yeah, I think pizzas fun and uh I think, I think it's quite easy and kind of enjoyable to learn. So, so I recommend that you go through like the most important topics and won't ask you about like very kind of specific types of pediatric childhood epilepsies or things like this. They will ask you about like common stuff like or important stuff like meningitis or cystic fibrosis. They want us, they won't ask you about like weird things that uh they may show you like some uh not, not easy GS, but chest x rays or Abdul x rays. So it's worth looking at, for example, chest x rays of uh infants who are have trouble breathing. Um So I think I had a question like this at some point and it turned out to be respiratory respiratory distress syndrome. But you know, that's, that's a very common topic. So essentially try to be aware of what topics are common and learn them quite well and just be aware of the kind of my kind of less important topics. So we can roughly kind of guessed answer and I wish you good luck and I hope that was useful. And uh uh yeah, and we'll probably try to get to you the slides somehow. Is that possible that yes, um the slides will be uploaded onto medal um catch up content. So the slides will contain some of the explanations for the questions that we've missed out. So don't worry about missing those out. Um Otherwise Thank you very much Suzanna for the session. We apologize that went a bit over time, but we thank you for coming regardless. Please do fill out our feedback form that I've popped in the chart. We're also now halfway through the series with two more sessions to go. So be sure to check out our Facebook event link that I've put in the chat. Um I believe Susanna will stick around for a bit to answer any of your questions. Um Otherwise thank you for joining and enjoy the recipe evening. Yeah, thank you guys. We'll see you later. Um Susana, if there's no questions from the audience, um, just feel free to leave whenever. Thanks very much for coming on again. Thanks. See you later.