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As you, as I already said, there's just so many conditions and presentations in. So um there's a lot to cover but these, this is really useful as we've said before to like base your revision off if needing something. Um So let's get started with the first question. So, question 1, 11 month old girl brought into GP with coral symptoms and a mild fever. Dad reports, she has been breathing fast and just isn't herself. Um So she's usually breast fed and is feeding as much as usual. Um and has a n A normal number of wet nappies. There's no significant past medical history but dad reports, there is a family history of asthma on examination. There are signs of mild respiratory distress with nasal flaring. Um There's no signs of clinical, no clinical signs of dehydration and on auscultation of the chest, there is mild wheeze and crackles obs are as follows. So, resp rate of 60 heart rate of 100 and 40 flats of 94% on room air and temp of 37.9. Um So I think uh so which of the following features of this presentation is the most concerning and would lead you to consider referring this child into hospital. So a family history of asthma B, nasal flaring c fever, D age under 24 months and e respirator of 60. So that will set up the pole. Now give you guys a minute or so to answer that. Mm. Oh, ok. I reckon we'll go ahead and end the pole there. So it looks like it's about 5050 a little bit more leaning towards B um with a few going for e um So the correct answer is actually e um I can see why a lot of people went for. The answer would be. And what did you say? Sorry. The correct answer is e uh Raspberry of 60. Um So just talk a little bit about why that's the answer. So, um the question here isn't asking what the diagnosis is, but um should be sort of clues from the vignette that this baby likely has bronchi bronchiolitis. Um And what kind of leads you to think that is? So the coral symptoms, um the fever, obviously the um fast respirate, the tachypnea, the respiratory distress, um and the wheezing crackles on auscultation all kind of lead you to, I think this is kind of a bit of a classic case of bronchiolitis as well as the age of the child as well. Um So this question is asking you what feature from the presentation is the most concerning and we want you to refer them into hospital. Um, so if we just go through the answers, maybe that's the best way to think about it. So, um, a family history of asthma, um, that wouldn't in itself make you particularly concerned in a child of this age that's not really relevant at this point. You don't start to think about an asthma diagnosis until they're a bit older, sort of past a sort of four or five year old age. Um So it's not really relevant to this question and wouldn't necessarily make you concerned. Um If they were a bit older, then you would definitely take that into account and kind of that might lead you to a diagnosis, um be nasal flaring. So a lot of people went for this one, that is a sign of mild respiratory distress and that's kind of pointed out in the question. Um But that on its own, um isn't necessarily a concerning feature that you would send them to hospital for. So this is just based off the nice guidelines, obviously, in the context of this question, it's a little bit tricky because there is a respirate of 60 the mild nasal flaring. So that together makes you concerned, but the nasal flaring on its own if the child was well. Um otherwise, well, is not that concerning. Um So it's not the most concerning feature of this history at the moment. Um definitely should like make you stop and think any kind of sign of respiratory distress is a bit of a red flag and definitely something you should look out for, but it's not the most worrying thing that's going on here. Um, see fever again, like they had a mild fever at home and were, well, otherwise they could be managed at home. That's not necessarily something concerning if they're otherwise. Well, um, and her fever is quite mild in this history. Um, The age under 24 months, um That's just the age group who get bronchiolitis. That's not necessarily a worrying thing tends to be under a year, but it can be up to two years. So that's a concerning thing at all. And then respirate of 60 is the most concerning thing here. That's really high respirate. Um In the nice guidelines, a respirate of over 60 is something that should lead you to send the child into hospital to be seen. It's pretty high for a child of this age. I've put in um few charts later in this presentation. I'll show you guys those but having kind of an awareness of the upper limits of this kind of thing can be really useful. It's a lot to remember but that not rote learning it, but just kind of being aware um is something to think about. So I just move on to the next slide. Um So yeah, just a bit about bronchiolitis. So, um I'm sure you've all seen bronchiolitis if you've been in a hospital, if you've had any peds placement, it's really, really common, um especially in winter. Uh, but you actually kind of see it all year round these days, often caused by R SV. So that's Respi respiratory synthetical virus. Most common up to one years old, as I said, but kind of kind of uh up to 24 months, um particularly if they've got sort of other health problems going on. So one thing is uh premature babies, they tend to get sort of chronic respiratory issues and they can present a bit later with bronchiolitis. That's when you tend to see that. So presents with everything that we kind of already discussed in the question. So coral symptoms, that's your kind of classic cold symptoms. So snotty nose, that kind of thing, signs of respiratory distress, fast breathing, poor feeding and dehydration. And that's a really key thing to kind of think about and find out in the history because that can definitely sort of lead you to think that this child is more or less sick. Um And then you can hear wheeze and crackles on auscultation. Um So a lot of infants can be managed at home and a key part of that is just making sure the parents know when to get further help. Um and what they can do at home to sort of make the child feel comfortable and things like that. Um As we've discussed, the need to be referred into hospital and there's concerning features and on the right, you can just see um a screenshot of the nice guidelines of when to refer. So there's, you know, either calling 999 in the instance if you're seeing them in GP or in the community, um if they're sort of really, really unwell or referring them into Ed, if they're sort of definitely unwell but not needing immediate emergency care. And then the management hospital is largely supportive when they are there. So oxygen supplementation, um and that can be like sort of more or less um intense, I suppose. So that can either just be sort of nasal cannula going all the way up to sort of ventilatory support and they use um high flow humidified oxygen for that. And sometimes you see babies with these kind of like boxes on their head. Um and that's for those really sick babies. Um and you can do suctioning and just making sure they're maintaining adequate intake because that's one of the difficulties with these Children is that they're not getting in enough sort of fluid and um intake and things like that. Um and just a few key points for rest. So, I mean, as with, as I said, at the start with peds, there's no way I could really cover everything that comes up. Um But just to sort of key things to think about knowing the signs of respiratory distress is the biggest point of advice I can give. That's both for real life and for exams. Um That's how you kind of differentiate between a not sick child and a really sick child. And kind of knowing how they get into mild, um moderate and severe. And I put that was on the last slide. Actually, there was a little screenshot there, the signs of respiratory distress and just kind of learning those really useful um having knowledge of different ranges um for different age Children. So just kind of knowing what observations are kind of vaguely related to different ages because obviously that changes. And again, that's gonna kind of point you in the direction of whether a child's really sick or not. And in the next slide, I've popped on a screenshot of the pugs charts for anyone who hasn't seen that before. So we can have a quick look at that. Um As I already said, don't forget to assess for dehydration. So like asking about feeding and wet nappies, number of wet nappies, that's a really important thing for this age of child. Um That can kind of help you determine if they are dehydrated or not. And then I've just put a little bit of information in for you guys to use for a vision if you want um for about kind of things that tend to come up really important. So, croup epiglottitis and viral induced wheeze obviously, asthma is a big one, but I'm not gonna go into that here because that's a huge topic in itself. But that's just something that does come up quite a lot. The management of asthma and viral wheeze. So there's a little bit of information about each of those. Um, if you guys wanted to go over those in your own time, but those are kind of the main ones with bronchiolitis that I think tend to come up quite a lot and kind of knowing the key differences between them is really useful, especially with bronchiolitis, asthma and viral wheeze because they kind of go with age and the age of the child really helps you determine which one it is and there is a bit of an overlap. So just knowing about that would be really useful for exams. Um And then this is the pugs chart that I was talking about. So this is uh NHS Scotland, but it's very similar to the UK one. It's just you just use this one because it's smaller and has all of them on one page. Whereas if you've seen the P chart and they in England, they're just huge and I couldn't fit onto one page. But it's just to show you guys and give you an idea of like the different age ranges and how they break it down and what kind of for you to worry about and not to worry about. As I said, I think that kind of learning these off by heart would just be a bit of a waste of time. It would take you way too long. It would be difficult but just trying to have a vague idea of what's worrying and what not, what's not worrying. So, uh, would be really helpful for exams but definitely for real life as well. Ok. Um, all this was just another thing that I popped in is, um, fever in the under fives. I don't know if people have come across this before. I'm sure you have. It's a nice guideline. It's a traffic light system for um clinicians both in the community and in ed of kind of treating Children um with fever in um age under five. And it's just about things that are worrying and not worrying. So obviously you've got green low risk um but intermediate risk and red high risk. And again, this is just helping you determine which Children are really sick and which are kind of less. So um because it is really, really difficult and um yeah, so that's just again, something to be aware of can be really useful in kind of identifying those Children. Um ok, you want to question two. So um two year old baby boy is brought into Pe's Ed by mum with vomiting and abdo distension. Mom describes the vomit as green in color and one question she doesn't think that um the baby has passed meconium yet. Um He has been irritable and hard to console he was born at 39 weeks with an uncomplicated vaginal birth. Um When you asked mom, she says that pregnancy was mostly unremarkable. Um So given the most likely diagnosis, what is the Gold Standard investigation to confirm this diagnosis? So, a Abdo x-ray B rectal biopsy, C, Abdo ultrasound D CT scan uh or e clinical diagnosis with no specific investigation. We'll give you guys a minute to answer that form or I think we've got quite a good amount of answers. So maybe we'll end it there. Ok. So, um a little bit more of a split here. I don't know if I've made these questions a bit too hard or not, not that obvious because again, uh most people have gone for um c but the correct answer is actually the rectal biopsy. So, um got about 29% going for the correct answer there. Um So we'll just talk through this question. Um Kind of what makes you get to the diagnosis. So, um the diagnosis from this question is most likely Hirsch's um disease. So that's what you're kind of basing the investigation of. So the key points in that question that lead you to think that um the green vomit, um the not passing meconium is the kind of biggest clue in this question. If a baby hasn't passed meconium in the 1st 48 hours, you tend to really worry and that's kind of a bit of a red flag sign for Hirschprung's um the vomiting and abdo distension as well. All of this kind of lead you to think that this could be Hersh Sprung and the Gold Standard investigation to diagnose this is a rectal biopsy. So you can do um ABDO X ray or ultrasound before that point to kind of investigate for um enterocolitis. But the actual Gold Standard investigation to confirm the diagnosis of Hirsch's is a rectal biopsy. Um I saw this question come up quite a lot on past med when I was revising and it was kind of one of those key things that once you know, it, you never forget it and will always get it right. So I just thought it would be quite a good one to go over. Um So just moving on to a bit about hash bangs itself. Um So the baby in this vignette is kind of a classic presentation of Hirschprung's disease. Um It can present sort of with acute intestinal obstruction shortly after birth um or present a bit more gradually. Um So delay in passing meconium and for anyone who's not aware, um Meconium is the kind of the first poo that babies do straight after being born. And um sorry, I said 48 hours earlier, but it's actually more than 24 hours is a delay. So you just, that's something that's kind of a bit of a key point if that's if that's not happened yet. Um then you start to worry a little bit. Um, chronic constipation since birth, abdo pain and distension, vomiting, and then poor weight gain and failure, failure to thrive. Um So what is Hirschprung's? It's congenital condition um where the nerve cells in Myer plexus are absent in the kind of most distal part of the bowel and rectum. And the key pathophysiology in this is the absence of the parasympathetic ganglion cells. And these are the cells that make the gut, um, move the stool along. So essentially, it just gets to that part of the bowel and can't move any further and gets stuck and that cause the causes the obstruction. And it's also why the meconium it's delayed and being um passed. Um, so management, as I said, you can do an abdo x-ray for obstruction, rectal biopsy is what you do to confirm the diagnosis. Um And then obviously, there's things you might do if the child is really unwell. Um, if they have enterocolitis, which is one of the complications, they're gonna need fluid resuscitation and management of the obstruction. And then the definitive management is just to remove that section of bowel. There's nothing you can do for it at that point, you just remove it. And, um, after that's been done, they tend to sort of make a full recovery and doesn't really cause some problems later down the line. Um, there's just a little bit there about hirschsprung associated enterocolitis. So that's the inflammation of and obstruction of the intestine occurs in about 20% of neonates with Hirschprung's. Um And they kind of present really, really unwell 2 to 4 weeks. Um from birth with fever distension, diarrhea with blood in it and kind of features of sepsis pretty life threatening. Um So needs to be kind of managed appropriately um, emergency situation. Um Yeah, so that's just a little bit about problems. And again, I've kind of just rather than teaching you about every P ABDO condition, I've just kind of thought of some kind of general pointers for ABDO. So the kind of most common presentations that you see are constipation, abdo pain, vomiting and these are really nonspecific. Um And that's why a thorough history and examination is so important, determining whether the child is dehydrated and then just kind of learning Abdo pain red flags, I think is one of the best things you can do for exams. Uh that if you do that, then if any of them come up in a question, you kind of immediately know. 00, I think this is this for that. I think this child is quite sick. So they need this management as opposed to this. So it's just that's kind of the best thing you can do. Um The the biggest consideration with like kind of acute ABDO pain is whether this is something that needs urgent management or, or it's kind of fine, it can be, can be a watch and wait. And there's obviously a few things that need sort of urgent, urgent, like particularly surgical management um that you can learn about. Um I've just given you an example of like red flags for harsh rungs, for example. So delay in passing meconium um symptoms of constipation, abdo detention and family history. So, like if any of those came up in a question which it did in this question, you would then sort of immediately be thinking, OK, I think this is Hirsch's and that, that's gonna kind of guide the answers from there. Um On the next slide, I just made a little table for revision of like how you can sort of structure, revision of abdo conditions. Again, there's so many to go through in peds. But um when I was revising, I kind of just divided them up into age groups. So neonates, infants and Children and adolescents and then kind of things that require urgent management and then kind of other really common causes that you see, and there is a huge amount of overlap again, of course, um between the age groups, but there are definitely things that only tend to come up in one age group or the other. And that can really help kind of um guide your answers of questions if you sort of know what kind of age groups have different things. Um OK. Move on to question three. So two year old girl presents to d after parents witnessed a seizure at home. They report she's been unwell for 24 hours previously with a fever. They have not noticed any rashes. Um and they think there's been an upper respiratory tract infection going around her nursery. They report the seizure lasted around two minutes and describe it as stiffening and jerking of her arms and legs. It has now stopped and she's been well since she did not injure herself during the episode On examination. She is alert and happy in mom's arms. She has a snotty nose and a cough and she's a bit hot and sweaty. There are no added sounds on auscultation of the chest and no other obvious sources of infection. Um When you examine her, there's no rashes or no focal neuro signs. One of our observations are within normal range except a temperature which is 38.9. So what is the most appropriate management at this stage? So a refer to pediatric epilepsy clinic B, get rectal diazePAM C reassure parents and give advice for potential future future seizures D MRI head or E um and E eg so I'll give you um minute say to answer that got quite a lot of answers there. So we can probably end the pole with that. Um So bit more of a clear question this time because I think the majority of people got the right answer there. So the correct answer is see, reassure parents and give advice for potential future seizures. So well done guys on that one, the diagnosis that I'm kind of getting at in this question, um is most likely a febrile convulsion or seizure and the kind of things in the question that kind of point towards that. So previously been unwell with a fever, had a fever. Currently, um seizure lasted two minutes and has now stopped. She's now alert and quite well snotty nose and cough kind of leads you to think there's an infection, a source there of the fever and of course her temperature of 38.9. Um and that kind of all leads you to think this is probably a simple febrile convulsion. Um So Children with simple febrile seizures who recover quite rapidly, which she has in this question and otherwise, well, which again, she is they don't require any further investigation. Um So management at this stage would be to kind of reassure parents and give them advice for if this happens again in the future, what they need to do and when they need to kind of seek further help, um the kind of underlying cause here is most likely going to be that upper respiratory tract infection that's going around her nursery. She kind of has signs of that in the history and you've got kind of quite a clear sort of cause for um of the fever here if it was a bit less clear. Um and there was anything that worried you, you then would want to kind of investigate and make sure you're not missing any sort of worrying infections that could be brewing here or underlying and that have caused causes febrile convulsion in this history. You know, she seems quite well as a clear source. I think you'd be pretty happy to sort of reassure parents and kind of send them on their way with advice for the future. Um, so just thinking about the other answers, um at this point, you wouldn't refer to a pediatric epilepsy clinic. She's only had one seizure. Um And you're pretty sure it's febrile at this point. So she doesn't need to um see them. So this is something it's pretty common and that she'll grow out of be of rectal diazePAM. Um That's something you'd start to think about if she was in um status, but she's not, she's stopped seizing, it's only been two minutes. So that's not an appropriate management at this stage. And both with MRI head and the eeg again, she doesn't need further investigation. Um And that's not something you'd want to think about really um at this point. So just moving on a little bit about febrile convulsions. So, um they're a type of seizure that occurs in Children with high fevers, um tends to be between the age of six months and five years old. Um They're really common. They happen quite a lot. Um They're not caused by epilepsy or any other underlying neurological pathology such as like uh meningitis or tumors um to make a not to make a diagnosis, other neurological pathology must be excluded. So, meningitis, that's why in the question it was saying, you know, does she have a rash? Um no focal neuro um signs. So again, and if she had that, you might think about space occupying lesion. Um one to always think about is non accidental injury that that can cause seizures and you just want to be mindful that that's not what's going on in this question or in any question for that matter. Um And then electrolyte abnormalities can also cause seizures, seizures. So if you were worried, um then you could investigate any of these things. I think in this question, it's quite kind of clear what's going on. But if it were a little bit more sort of not so clear, then you might want to think about investigating um for any of those things. Um So management just yeah, making so identify managing the underlying source of fever um and infection. So you can just control that with analgesia. They don't require further investigation if they're simple, complex febrile convulsions made further investigation and complex tends to be when they last longer than five minutes um or they have another seizure quite um soon after the first one. So that that is when it becomes more complex and that might be further investigation. And then the advice that you want to give parents on managing a seizure is kind of standard first aid thing that we would all know, but is not necessarily like something that a parent might know. So it's just, you know, making sure they're staying with the child, putting them in a safe place, putting them in recovery position and then calling an ambulance if the seizure lasts more than five minutes. Um and it's just the point at the bottom that the first seizure should always be seen in hospital um as this child has. But if the parents are kind of fe feel confident in the future and feel like they can safely manage a child at home, then they can and just visit their GP the next available opportunity. Um So yeah, that's just kind of the main thing with febrile convulsions, a lot of reassurance and education. Um But yeah, move on to the next question. So it's quite a straightforward question. Um So question four, a new mom comes into her GP practice for her six week baby check and she asks for advice about what developmental helpful when to be concerned in the future. So which of the following is a red flag that may suggest developmental delay. So a 1212 month old, unable to sit independently b 1414 month old, not walking independently. C A four month old, unable to grasp an object with thumb and fingers. D an 18 month old using only 5 to 10 words or E four weeks. So not yet, I'll give you a little bit of time to answer this question, making a good amount of answers. Um So really well done guys mo most of you got that one correct. So the correct answer is a, a 12 month old, unable to sit for developmental milestones. Um So just to go through the answers really quickly. So first one, yeah, is a red flag for developmental delay, uh independent kind of point that you start to land. Um B um they should be able to walk independently at 15 miles. All right, 14 month old is fine. You I still got a so that, you know, yes. OK. Um Only normal cartilage a red. So we haven't that and he um maybe six weeks old. So again, four weeks old is so stuff. Mm It, it's really common in real life. Parents do kind of thing quite a lot. So it's good to have knowledge of it. Um It's broken down into gross motor, fine motor language and personal and social. Um There is a lot to remember. So it may be easier to just to learn the red flags. So that's kind of most likely you're gonna be asked about. Um And there can be normal variations of development, the lost development, they've lost developmental milestones if they once had them and now no longer have them. That's obviously really worrying. And that would be a big, big red flag and then you've just got different ones for different, um, kind of areas. So, you know, as we said, sitting unsupported, not standing independently, not walking, not running, et cetera, I'm not gonna go through all of them. But, um, I would, yeah, my biggest hit would be just to kind of learn those red flags. Um, on the next slide I've put kind of a big table with all of those, um, developmental milestones in. I personally didn't like, learn all of these for exams. I think that's a really difficult thing to do and it's gonna take you a long time. Um, I guess again, just having an awareness of the different areas that they're broken down into and kind of the red flags of what you should expect at different ages is probably your best bet of how to do it. But there are resources out there with all of them on if you do. Um, kind of want to learn it that way. Yeah, it's a really difficult topic and, um, kind of hard to get your head around, I think until you actually kind of hang out with any Children, it's really hard to sort of conceptualize, but I did watch a few youtube videos about it um, before, oy, and that kind of thing because that can be quite a good way to kind of actually see it in action. So that would be another tip. But um, yeah, that's development, move on to question five. Um So three year old girl was brought into GPP by her gran who reports a new rash. She reports the patient has been a bit unwell recently with a fever paris symptoms and a cough three days prior, the rash then started yesterday first on her face and spread to the rest of the body. Gran is unsure of the patient's vaccination history. Uh On examination, you can see an erythematous maculopapular rash on the face and body in the oral cavity. You can see small white spots on the mucous membranes. The patient is currently afebrile. So this is a picture of the rash. What is the most likely diagnosis here? So, a viral exanthem B measles C chicken pox D rubella and e scarlet fever. So I'll give you a little bit of time to answer that. Ok. It's been about a minute. I reckon we'll end it there. Um So yeah, really well done again guys, this um the most likely diagnosis here is measles and majority of you got that right. So this is quite topical at the moment, obviously, in the UK measles is very much on the rise, just kind of seeing more and more cases of it. Um and it's just really important to know about and probably will come up in exams. So, um kind of the key point is in the vignette that would lead you to this diagnosis. So, pro drone with the fever, um cries or symptoms and cough three days prior and then a rash starting first on the face and spreading to the rest of the body. That's quite classic measles. That's also a thing for some other rashes as well, which will come on to. But that's one of the things from the measles. Um um The vaccination history being mentioned. Usually if that comes up in a question, it does tend to be relevant. Sometimes it can be a bit of a red herring. But I think in this question, what you might already be thinking, oh, this might be needles. Um That kind of pointer of vaccination history might, might kind of push you over into definitely being that. Um And then the, the description of the, the rash is kind of a classic measles rash and the kind of final thing that definitely seals the deal is the small white spots in the mucous membranes of the oral cavity. Those are called coli spots and they're very classic measles signs. So if that's coming up in a question, then we kind of think this has definitely got to be got to be measles. Um So we'll just talk a little bit about measles in the next slide. 00 OK. One bonus question there. But um yeah, how it managed supportively um with rest analgesia and fluids. So there's not actually that much you can do for it, but one of the key things to know is it's obviously highly transmissible So um the child needs to stay off nursery for four days from the onset of the rash. So for this patient, the rash started yesterday. So she needs to stay off nursery for a few more days. Um So a little bit about measles, so highly communicable infectious illnesses. Uh It's kind of on the rise at the moment and this is they, they attribute this mostly to sort of declining vaccination rate in the. Um, so seeing kind of seeing more and more cases of it. Uh So you get the pro Bye con. Oh, and then a few days. Oh, and copy the when things pop up. So you've got the kind of pro from day one with the fever and then the rash pops up around start. Um, and the rash tends to be kind of, I put a few pages in the next room. Um, ok. At, at, so those always helpful. But, um, if those kind of are described in the question and it's pretty like clear that it's measles, um, just a few complications that can happen, which is kind of why we back against it. Um, pneumonia, dehydration, encephalitis, hearing loss, vision loss, and then in extreme cases, um, uh, uh staff as well, um, as I said, it's just rash, it's not disease as well. So if you do ever see it in, um, then you have to kind of notify the government that you have seen it so that they can track cases. Um These are some pictures of measles rash and different skin tones. Um, as you can see on the picture of the right, it appears much more sort of hyperpigmentation than an erythematous rash. It's just having that awareness doesn't look the same in all skin. So you can't really rule just having a look at different different voters tone is always really helpful. Um And then I've just kind of done a bit on uh other common pediatric rashes. Again, this is quite a large topic, things that come up that they can often be described really similarly. And so kind of having an awareness of those like key pointers that differentiate them is the best way to go about it. Um The details are usually in the history um and like the photos but just kind of those key points. So carer and that's kind of a raised blotchy red rash. I've seen this before, usually have quite history and there may be kind of precipitating factor, you know, something they reacted to chicken pox. Obviously, everyone's usually aware of this one and you get a vesicular rash and fever, it's very contagious um on the stomach back and face kind of these really itchy red papules, I'm sure we've all had it. So I know what it's like um scarlet fever. This one, this is one of those ones that has a very classic history. So you get the strawberry tongue, they get the kind of sandpaper rash, the skin desquamation. So that one's usually quite easy to kind of figure out from the question. Um Impetigo is the kind of honey colored crusty rash that they, that Children tend to get around their mouth. Um And again, that can be quite obvious from the history uh atopic eczema, obviously, this is quite a common one as well. And that's the classic itchy red patches, uh plaque so often and cold and then you can, you know, get the like moist erosions on the face and neck, upper trunk, elbows and knees, um rubella, this is o otherwise known as German measles. Um And again, you get pink macules and purples. So you kind of, you can kind of see that they're all, they all sound really similar. They'll just always be some kind of key thing in the history that points you in one direction or the other. So just having knowledge of those is what's really helpful. And this was just a algorithm that I found when I was researching these rashes that was I thought was just quite helpful. So if you get the slides at the end and want to use this for revision, um then yeah, I just thought it would be that would be good. Um So moving on to question six, so four year old girl sent to the emergency department after her GP found a profound isolated proteinuria on examination. She has marked edema with facial involvement, the blood results are as follows. So, um I won't go through all of them. I'll let you guys have a read of them with the question, I'll give you a little bit longer. So which drug should be prescribed to minimize compli complications um from her likely underlying diagnosis. So, a prednisoLONE b low molecular weight heparin C albumin D trimethoprim or C or E walking up. Well, it's been about a minute. So we'll probably close that one there. But really well done guide is again, majority of you got the answer. Correct. So, correct answer is a prednisoLONE. Um So this girl most likely has a nephrotic syndrome. And um in Children, we tend to assume that if they have nephrotic syndrome, the most likely underlying underlying diagnosis is minimal change disease. Um And that is the case in about sort of 90% of Children with uh nephrotic syndrome. It can be caused by other things, but they tend to kind of assume that at this point just because it is so common and the predniSONE is to kind of prevent further complications as a result of that. Um When I was researching this, it, it did say that um because technically minimal change disease does have to be diagnosed with a biopsy. Some pediatricians now will kind of call it idiopathic nephrotic syndrome until kind of proven otherwise. But the the management is still the same. So you'd still want to get predniSONE at this stage. Um So kind of what's pointing to that in the question. So the proteinuria obviously is a big thing with the, the edema with facial involvement. So that's kind of your red flags right there for nephrotic syndrome. Um just looking at the blood. So she's got really low um serum albumin. And that's kind of in keeping with the um nephrotic syndrome uh where large proteins sort of leaking through. And um a key key risk for Children is that they can become dehydrated. So sometimes you might see changes to their sodium and urea, but in this case, they're kind of they're fine within the normal range. Um So just going through the other answers. So um the low molecular molecular weight heparin, um this is given to adults with nephrotic syndrome. So I think a few people put this as that answer and that's due to the kind of thro thrombo pro thrombotic state um that nephrotic syndrome causes you to be in, but that's not routinely done for Children. Um Albumin don't tend to give this unless kind of under very specialist advice. Um and it, it can transiently correct the problem, but it's not gonna resolve it. So it will bring the serum albumin up, but it's not gonna stop it from leaking um kind of out through the kidney. So it doesn't resolve the problem. Um cycloSPORINE, that's a second line drug in um nephrotic syndrome. So they might give that after prednisoLONE. Um or in other case, if they can't have pre predniSONE for whatever reason. Um But that's not first line and then trimethoprim is not routinely given. Um There is something to say. So these Children are at high risk of infection when they have nephrotic syndrome, but you wouldn't give kind of preventative antibiotics or anything like that. Um So just a bit about nephrotic syndrome is quite the word heavy slide, but quite, quite a tricky topic to get your head around. I think um it occurs when the basement membrane in the glome glomerulus uh becomes highly permeable to proteins. So then you're just getting proteins leaking from the blood into the urine and that obviously explains why you have the low albumin and then the protein urea, it's most common between the age of two and five years prevents with frothy urine, sometimes what the parents might notice um generalized edema and sometimes por as well. And you get this kind of classic triad of low serum albumin, high urine protein and then edema. And that's kind of your classic nephrotic syndrome triad. Um And then there are kind of other features that you can get in nephrotic syndrome. So, deranged lipid profile, high BP. And then as I said, you get this hypercoagulable prothrombotic state. Um So in, in peds, it's 90% of the time caused by minimal change, disease. As I said, there are other causes and um some of those are systemic illnesses. So that's just something to be aware of. I think most likely in an exam scenario, they're gonna do minimal change disease. But, um, you know, just look out for any question if there's anything that might lead you to think has been caused by diabetes or infection and then, um, management should be managed by pediatricians. Um, kind of further down the line. Obviously, the first, the first case, if you're seeing them in Ed, then give them some predniSONE. But um after that point, it's kind of being passed over to the renal specialist, the pediatricians, but kind of for general management, they tend to give them steroids, low salt diet, diuretics, albumin infusions and then they might give antibiotic, prophylaxis in very severe cases. Um So yeah, it's a bit about nephrotic syndrome. It's quite specialist, but it's just kind of quite a classic diagnosis if you get that, that triad want to be aware of. Um moving to questions seven. This is our last question. So question seven at her six week baby check mom reports. Her new baby has not been feeding. Well, she describes her seeming out of breath from feeding and when recently weighed by the health visitor, she had failed to gain weight on examination. The baby is ayano and a pansystolic murmur is heard which is loudest at the lower left sternal edge. Um So what is the most likely diagnosis at this stage? So I'll give you a minute or so to answer that one. OK, on the polder. Um so well done guys. This was quite a hard one. Majority of you got the answer, right? Which was c but quite a lot of people put e as well and those are kind of the two that are definitely be stuck between. Um knowing the difference between them is comes down to knowing your murmurs really well, so well done. Those of you who got that right? Um So if we just go through, so this is quite, quite vague history at first. Um a baby that's kind of not feeding, not, not, not gaining weight. That could really be anything at the start. I think the key things that kind of you should pick out in this presentation. So the shortness of breath when feeding um and kind of the not feeding and fail gaining weight, you could describe as failure to thrive. Um and the examination is where this diagnosis becomes a lot more clear. So, um the baby being acyanotic, I think that's quite a big clue in itself that you're starting to think about something cardiac here. Um And then the murmur being heard is obviously a big clue. Um So looking at the answers A B and D are all cyanotic congenital heart conditions. So as the baby's a cyanotic, it can't be any of those and that's kind of leaving you with C and E at this point. Um and the way to tell is tell the difference is with the type of murmur, as I said. So A VSD will give you a pansystolic murmur heard um loudest at the lower left sternal edge and a patent ductus arteriosis is a continuous crescendo descend murmur under the left clavicle. So, yeah, really, really well done if you got that right guys, that's definitely a hard one. Um So just to talk a little bit about um congenital heart conditions, not gonna go into a huge amount of details. It's a really complicated topic. Um But I think the key thing to understand for finals and also for placement is the difference between the acyanotic and the cyanotic heart defects and how those present. So, in an acyanotic heart defect, um it's a left to right shunt. So oxygenated blood is going to the right side of the heart. So you're still getting blood through the pulmonary circulation and this is why it's a cyanotic, the patient's still getting a good level of oxygenated blood around their body. Um So these are things like atrial septal defects, um ventricular septal defects, um PDA and these over time tend to cause heart failure and arrhythmias. So, um how do they present? Sometimes they're picked up in um antenatal scans, sometimes they're picked up at six week checks with a murmurs kind of just incidentally heard um or even in their, their IP when they're, when they're still in the hospital when they're first born, um, or they can be picked up just with how they're presenting. So, um, either breathless, sweaty and especially when they're feeding. Um, because obviously when they're feeding that, that's when they're kind of leading to, um, that's when it kind of shows the most. Um, and then inadequate weight gain, of course, if they're not being able to feed properly, um, and it kind of depends on the size, how far into life it'll present, it can present much later into life when they are um, Children rather than sort of in infancy. Um, if it's a smaller defect and that would present kind of, yeah, similarly, but with sort of these heart failure symptoms, um because eventually a left to right shunt leads to this kind of right sided overload. Um right heart failure and this pulmonary hypertension. Um So it will kind of present with those type of symptoms later in life if it is kind of not picked up earlier or left untreated. Um, so treatment should be coordinated by a pediatric cardiologist, very specialists. And if they're gonna need surgical intervention, obviously, obviously they're the people to do it. Um And it again, it depends on the size of the defect. So you're gonna either kind of leave it, watch it and wait if it's small and it's not causing them too many symptoms. And that would be what would happen if you kind of picked it up incidentally and they didn't have any symptoms. So if you pick up kind of one of these murmurs in a night p, um, they do tend to watch and wait because at that point they don't really know necessarily, you know, if it's gonna even cause them any problems. So it does depend on the size very much. So. Um, but ultimately, the only thing to correct it will be surgery later down the line, um, or sooner if they need it. And then there's just the murmurs for the acyanotic um, heart defects. And these are really tricky to learn. I think. Um I'm not sure how much they're really gonna come up. But I think kind of, yeah, as I said, the key difference is just knowing how one or the other presents. So a cyanotic or cyanotic. Um, but there's the murmurs there for you guys to look at um, during your revision if you need to. And then finally just looking at the cyanotic congenital heart defect, um just the main two that I've focused on here to Trelegy of fallow and transposition of the great arteries. There are other um, conditions that would come under this umbrella, but these are kind of the main ones. And so looking at thinking about that as compared to the acyanotic, these are right to left shunts. So blood bypasses the pulmonary circulation and therefore these babies present as cyanotic um or collapsed in the first week of life. And the key thing to note here is that they tend to present sort of a week or two after being born. So, not straight away. And this is because that's when the doctor's arteriosis usually closes and up to that point, that's kind of compensating for the defect by kind of allowing blood to mix between the systemic circulation and the lungs. So they, they don't present immediately and the way you treat these initially is to give prostaglandins to keep that duct open. Um, so that they can continue to compensate until you can, uh, like correct it surgically. Um So presentation cyanosis, you get these tet spells, um which these kind of intermittent symptomatic periods where the shunt becomes temporarily worsened. And this is kind of usually during exertion. So this, this is probably gonna be in older Children, um, either on exercise or when babies are crying, it, they can kind of have a tet spell and they have this kind of cyanotic episode where they, you know, blew really unwell, um, and really short of breath and then it can pass after that. Um And then it can also present with poor feeding. Um, but usually these are picked up antenatally these days, like it's quite rare that it kind of gets to the point where it's been picked up because of the, the symptoms later down the line. Um And if it's a really mild case, it can be picked up in kind of an older child with signs of heart failure again. Um But that's definitely in the kind of milder cases. Um And in case you're not sort of aware of what um each of them are. So, transposition of the great arteries is just where pulmonary artery and aorta have been swapped around and they just correct that by swapping them back. Um And then to challenge you follows for defects um that affect the heart. So VSD pulmonary stenosis, right? Ventricular hypertrophy and an overriding AORTA. And we've just got the murmurs for both of those down there um for you guys to look at and then as I said, the management, so prostaglandins keep that duct open and then ultimately, they, they need corrective surgery. Um So that tends to happen quite quickly if they're, if they're really unwell. Um So yeah. Um that's everything guys. This is just what we've covered today with on the ML MLA content map. Um But that's everything for me. Thanks very much for.