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Not yet. No. Oh, hi. Hello. Hi. Yeah, welcome to SK 101 again. Thank you for coming in today. Um, we're gonna be doing pediatric history taking and it is a station that tends to most always come up. Um, we've got Kiara. Hello. I know it says Ronan, I'm actually Kiara. Um, so I'll be teaching the pediatric history today. Um, I'm one of the F four si work at York and Scarborough Hospital, which is where I did my foundation training. Um, I'm not actually a Cardiff graduate. I'm a Sheffield graduate, but I've kind of been brought onto the ki team to try and help you guys, um, prepare for your is at the end of the year. Um, well, I am a kind of grad as well, so if there is anything kind of specific I can, yeah, will kindly help guide those questions. Um, some of you I might have met during the mock a few weeks ago, um, where we did do a pediatric case in that um, exam. So I know at the time a lot of you said or fed back at the end that you hadn't actually done pediatrics Um So you did really well considering. Um So essentially today is just go back to basics, explain what's involved in the pediatric history and then we'll apply it to a case work through it. Um It'll be really great and Ris will be looking at the chat screen, so I won't see it once I'm sharing. Um But it would be really great if you can pop answers in there, um, or feel free to, to say them as well if um your chats not working. Um and hopefully it'll be an interactive session and you can get a bit out of it. Um But yeah, so we'll um we'll get started if everyone can hear. Um ok. And then I will share now. Yeah. Can everyone hear us by the way? Ok. Oh, ok. Can everyone see this? I no longer can see any of you but hopefully you can see. Yeah. Yeah. Ok. So as I said, I'm k um so I'm looking in pediatrics is a bit of an interest of mine since F two, I did a placement at Scarborough in it and really enjoyed it. Um So yes, uh today it's aes so essentially to try and understand the principles of pediatric histories. So what the sections are and then gather the relevant information um in that history. So looking at patient centered approaches, so that's more difficult to do obviously in a powerpoint. But um in kids you do have um a caregiver usually. So trying to incorporate both child and parent is really important with the pediatric history. Um, and then we'll apply the history to a case and talk about a couple of other um examples that you might get in your, er, is side. Why is a pediatric history important? They won't have any suggestions of what they think. Sounds like quite an obvious question is if you, uh guys feel free to write it on the chart and we've got one person saying differential diagnosis. Yeah, bro. Absolutely. Um So yeah, essentially it's the same for adults. Um, you need a history to be able to kind of figure out what your diagnoses are gonna be. Um, and then from that you might not have a specific diagnosis at that point. Um but it might help narrow it down or what you want to investigate. Um, and then through that investigation, you can then start your management. There is a bit of variation between the pediatric history in adults, um which we'll talk about um, in a bit more detail as the session goes on. Um, any challenges that you think, er, might, you might face in a pediatric history, any answers, anything that you think might be a bit trickier than with a, with adults. Um, it might be tricky if you've not done pediatrics yet. But uh we got a parent editor realizing. Yeah. Yeah, we've got distress from child and caregiver. Yeah. Brill. Um So, yeah, So you've got Children might be too young. Um, not able to give a history. Um, and therefore because of that, especially in sort of babies, et cetera, your history is going to be quite nonspecific, um, or potentially nonspecific. Um, they can't tell you if they've got too many pain. If they're a baby, they can't tell you, um, if they're feeling palpitations or anything like that. So, it's a bit tricky then in adults to try and hone in on um what's going on. Um And then, yeah, exactly. You've got your caregivers who i it's I put it in the challenges. Usually, caregivers are actually really, really good sources um because they know their Children really well. Um But like you said, which I haven't actually got on here when they've got added worry and stress, it can be a bit of a challenge trying to sort um or reassure um and give sort of advice that parents are happy with. Um So, yeah, absolutely. And then anyone got any ideas what the key differences in terms of sections are between the adult and pediatric history. Anybody know sort of extra sections that we look at in the history, birth and gestation, safeguard, immunization, neonatal history, developmental milestones. F Yeah, great. Well done guys. Um So yeah, so you develop milestones, birth history, which um we'll come on to in more detail, but I divide into antenatal birth and neonatal um and then growth patterns immunization. Uh feeding and social, which social there is the adult. But like someone said, the safeguarding element is more uh key in the children's side. Um, feeding history, we won't really cover a huge amount in this session. Um, just because it's in terms of your risky. Um, I wouldn't want you sort of spending too much time focusing on that establishing if a child's got reduced feeding is enough. Um, but being aware that in clinical practice, we do actually focus on the feeding side of things quite a bit. Um And sort of go into detail with that, but for your risky, just knowing if it's reduced is probably sufficient. Um And then definition, so this, you might probably already know this. Um, but some of these terms can sort of be used interchangeably. So it's just to start it off really. Um, so a neonate is, um, a child that's less than 28 days old. Um, infants are between one and 12 months. Um, a child is between one and 12 years. Um, adolescents are over 12. Um, a term baby is over 37 weeks and a preterm is less than 37 weeks. So it's just a few things just to clarify. Ok. So, um, the sections of pediatric history, so we've mentioned pretty much all of them. Um, but we'll just go through again. You don't have to do it in this particular order. I'd say obviously presenting complaint being the first one in adults as well or in general is the starting off and then you've got your history of presenting complaints, I'd then go on to systems review. Um But obviously, as you guys develop your history, like whatever order, as long as you're hitting all the points, you don't have to do it in the same order as I'm saying right now, um birth history, developmental growth immunization, you're past surgical, past medical, previous admissions, which is the same as adults, um, medication history and allergies as per adults, family history, social history. And then of course, your ideas concerns expectations, which I believe is a big thing in Cardiff as well. Um It was at Sheffield, um It was quite important and you risky to ask about that. Um You've got quite easy marks for doing that. So, um try not to run out of time before that one. So presenting complaint, um what are we wanting to ask in the presenting complaint or how are we, how are we going to ask that question, time upon? Yeah. So you're absolutely right. And in terms of presenting complaints, so that will become more under the history of presenting complaint. Um when we start to try and find out a little bit more. Um But your presenting complaint is more um what they brought brought in with. So that initial first question of, um how can I help you today? Um Or can you tell me about what's, what's been going on or, um, can you tell me about the reason what you've come in for today? Um So just that first open question which really like opens up the consultation, um, is sort of the best way. And then as you absolutely said, in your history of presenting complaints, so if the child's come in with, um, the parents says, oh, they've been breathing a bit faster than normal. Um, then, absolutely. So your history of presenting complaint, the timing of that? So how long has that been going on for? Um, what other sort of things do you want to know? Um, with the history of presenting complaint, we can sometimes apply it to, um, if it's someone comes with pain, the set of questions you tend to ask how it changed at all over the last few days. Yeah. Brilliant. So, finding out the pattern of, uh, of the symptoms, are they getting worse? Are they getting better? Absolutely. Anything else? No, it is not. Um, so, yeah. Yes, brilliant. So, um, so yeah, looking at, when did it start, how long has it been going on for, uh, how are they progressing? Um, and then yes, you start with pain and I find you can actually adapt it for other presenting complaints as well. So, um, to sort of, if the child comes in with cough, obviously, sight isn't really relevant, but onset, when did the cough start character of the cough? So, is it barking? Cough? Is it a productive? Is it nonproductive? Um, r doesn't really count but a for associated symptoms. So, is any breathlessness, um, any cyanosis things like that? Um Timing, does the cough come on more at night? Is it all always there? Is it a daytime thing? Um, anything that makes the cough worse? Anything that makes it better? Um, so you can kind of apply it loosely to other symptoms as well. So, um just to try and make sure that you cover the ground that you want to. Um and then systems review. So I got asked quite a few questions about this in the mock um about when, how much you cover of a systems review or how much detail you go into. Um And I think it very much depends on the presenting complaint that the child's come in with and the history of that, I'd, I'd definitely ask um questions first and foremost that relate to that and then you can always expand out. Um But do you, anyone got any sort of questions, general questions that you'd want to ask about a child or an unwell person coming to see? You just throw them out there? It can be any system and we'll go through them individually, any symptoms that you'd want to know if someone came in unwell, let's say, with cough or shortness of breath. Any trouble sleeping. Yeah. How many wet nappies? Brilliant. Yeah, that's it. Ok. So general, so general health of the child. So, have they got any fever? Um Are they more lethargic, has the behavior changed? Um Are they less interactive and playful? Um any rashes, um any weight loss, night sweats, those sort of red flag symptoms? Um And how's the hydration and feeding going? Um You may have your cardio respiratory. So you're cough breathlessness um in Children, wheeze and stridor, um which you see in adults, but we also see a lot of, especially at this time of year. Um cyanosis, um your palpitation and chest pain are a bit more tricky, especially in the young ones in the older teenagers, they'd be able to tell you. Um but in um sort of little Children, um it's a bit harder to determine in that um gastroin also abdominal pain, diarrhea, vomiting. Um Is the vomiting, is it projectile? Is it bilious? Um the projectile you want to make sure it's not a pyloric stenosis kind of picture. Um knee constipation, abdominal extension, um genitourinary. So any dysuria, hematuria, foul smelling urine, um increased frequency. Um and that someone said how many wet nappies as a child, toilet trained um neurological headache, seizures. Sometimes Children have funny turns which doesn't classically fit with a seizure. Um syncope, photophobia, neck stiffness, looking at your meningitis, uh sort of sign. Um and then your ent um is really important in kids cos um that can often be um a source of infection which if you don't look in the ears, you don't look in the throat, you'll miss it. So, um always remember that with, with kids um birth history. So anyone I kind of mentioned it a little bit earlier in what I divide it into. So, um you've got your antenatal, your birth and your neonatal. Um So if you start with antenatal, um anyone got any ideas about what we re, what we want to know in that sort of antenatal period or what we're looking for? When we ask those questions, please feel free to pop it in the chat. Abnormal scans. Brilliant. Yeah, mom. How is your pregnancy scans? All? Ok. Yeah, perfect. Yeah. So um you look, you look your birth if so how many weeks? Yes, he grow normal. Lovely. So yeah, so we've got a little bit cross between antenatal and birth. So the antenatal um is what I look at is how was the moment during the pregnancy? Is there any infections, chronic illnesses, uh pregnancy related ill um conditions, er any medication she was on any drugs, any alcohol and like somebody said as well, the abnormal scan. So that's sort of what I'm looking at antenatally um or wanting to find out and then birth someone's mentioned about the preterm and how many weeks? Perfect. Um Anything else about the birth that we want to know? Weight method of delivery prolong? Yeah, jaundice ischemia. I lovely. Well done. It's great. Such advances. So yes, we've got your mode of delivery. Um, so is it, um, so S DD means spontaneous vaginal delivery. Er, I OL is induction of labor. Um, then e the second one is the elective C section and the em is the um, emergency section. So we always, if they have an emergency or elective, we tend to ask them what the reason was. Sometimes it's parental choice. Um, sometimes, er, it's because you've had a previous one, et cetera. So just finding out why um gestation. Yeah. So were the term or preterm birth weight? That was lovely mentioned and birth complications. So was any resuscitation needed to the baby when they were born? Need any, um, was there any injury at birth? And was it prolonged labor? Um, obviously this is all quite in depth in detail and I for your, the purpose of your iy, you probably don't need to ask it in this level. Um, at least covering, was there any antenatal concerns, um, or any issues with the birth? Were they born on time is probably sufficient? And so I wouldn't get bogged down in need to know all of it, but it is useful to remember this, but in clinical practice as well. Um, but you can adapt how much um or little you need to use in your um iski. So as long as you're covering certain points and showing that you're thinking about it, I think that is the most important thing. Um, and then your neonatal. Um So this is the period after the baby's been born. Anything in particular that we want to know um in this first sort of few days or weeks and ICU stay. Yeah, issues breastfeeding or bottle feeding, right? Yeah. Um So well done. So any feeding problems. So yeah, establishing are they breast or bottle fed or are they mixed? Um any jaundice? Um So especially in the, you can kind of expect sort of from the day three onwards, you can parents, will you say? Oh, we started to notice jaundice and for most of them, it resolves um in some, it can be prolonged. Um We see that a lot in breastfeeding babies um and then infections. So were they treated for sepsis or suspected sepsis when they were born? Um And did they do admission to special care er, or the neonatal ICU? And if they did, how long did they need? And what was the reason? Um So that's your birth history and then developmental history. So this is uh a chart from osk stop, um which I thought was a bit of a nicer one. some of them could be quite er overwhelming when you look at them. Um I think having a rough idea of when Children are meant to be meeting certain milestones is important in terms of your risky, the purpose of asking the question are meeting developmental milestones or do you have any concerns? Is probably sufficient enough, um, and gets you the tick. Um, but having an idea of these milestones would be useful. I wouldn't say there's an easy way to remember them. It is just a case of familiarizing yourself and eventually you kind of just know roughly where, where they are. Um So, yeah, that would be probably an important one in exams as well, written exams. They like to ask those questions. Um And then, yeah, so that's usually up to the Children, four or five years old and then nurseries often do progress reports. So parents will tell you that the nursery is, um, has given the report and they're meeting all the masters they expect at nursery, um, school progress and attendance for school age Children. Um, make sure that they're not falling behind if there is what's the concern. Um, and then any parental concerns as well, um, is important to find out. So, yeah. Um, but for the purpose of you risky probably just asking any concerns developmentally. Um, any meeting milestones is sufficient and then you've got your growth. Um, so is the child gaining weight, uh, and growing, er, height wise along the centiles as we expect? So up to the age of five, we use the red book, um, and all the weights are documented in there and you can keep track along the centiles, obviously, if they're starting to drop centiles, um, then it may indicate some, um, chronic disease, uh, or something concerning with their diet, et cetera. So we need to look into that. But yeah, so asking the parents, are they gaining weight appropriately? Um Have they got the red book with them? Um Then we go on to immunizations. So again, this is similar to developmental in that you, you just need to be aware of um what vaccines did you when and again, it's not really, it's not an easy way to remember it or I've not found one. you just kind of learn and eventually you'll get there, exam, written exams are probably more important for this as well. But asking parents for their Children up to date with the vaccinations, um because if they're not, and you've got a child with a fever, you're starting to question, could it be one of these that are not vaccinated, vaccinated against? Um, especially with things like measles and mumps and making a bit of a comeback. Um, so it's important to ask. Um, and then this is similar to adults. So you're past surgical and medical. So, er, previous operations planned procedures. Um, it's helpful if you've got a child coming in with right sided abdominal pain, they've already had an appendicectomy. It's helpful to know that they've had their appendix out, um, and previous medical diagnoses. So, have they got any medical conditions? Um, sometimes you'll ask parents that and they'll say no. Um, but if you ask them, are they taking any medication for anything they'll say yes, inhalers and they don't really make the connection that the child's got sort of a history of asthma or things like that. So, asking questions in different ways can help you get, um, all the information you need. So I use an array of these. But yeah, essentially. Do they see a doctor for anything regularly? Have they got any upcoming appointments or referrals? Anything they take medication for, um, and any previous admissions? And if so what for, um, but again, for the purposes of OS or is, um, asking any previous medical history that we need to be aware of is probably sufficient as well and then medications and allergies. So, um, if your allergies, any me, any known drug allergies, if so, what's the reaction? Is it more of an intolerance or is it an actual true allergy? Um, and then finding out if they've got any food allergies as well, um, for example, Nain Cream, which they use in the ent, if they've got nosebleeds, um, that's got peanut oil in. So obviously, if a child or adult has got peanut allergy, you don't want to be prescribing them that, um, and then current medications. So, uh, are they prescribed anything? If so what's the dose or how do they take it? Um, I'll put both there but, yeah, adherence compliance. Same thing. Are they, er, following how they take it correctly? Um, big one with that is inhalers, um, and checking inhaler technique, er, and seeing when it was last issued et cetera in clinical practice, um cos not everyone is honest about that. Um And then over the counter um including vitamins. Um So you've got an overall view of what the person is taking. Um family and social. So family history again, um anything relevant to the history of a complaints um that runs in the family, uh any unwell contacts, uh parents, siblings, nursery school, uh Anything that seems to be doing the rounds um is helpful to know and any genetic conditions, social history is, is largely quite similar to adults. Um However, you do have uh you want to find out what the family dynamic is at home. So you want to find out who's, who's in the house. Um Is there any extended family, um half siblings? Um It's just a better idea to sort of understand who's at home with them. Um And it's quite important if there is a safeguarding issue going on. Uh any smokers in the family, um social services safeguarding concerns either for this child or previous Children. Um It's important to get an overview and it is a sensitive question. Um And I probably ask it in a similar way to how I'd go about asking adults. Um Do you take drugs or drink alcohol? Um sort of approaching it sensitively and just explaining that it's part of the history and we have to ask everybody. Um So it doesn't feel like people are being singled out. Um, and then nursery school attendance. Um, so are they attending, if they're not? Is it because of chronic illness? Is, have they been ill a lot? Um, is it behavioral, um, and then recent foreign travel important for infection sides? Um, and any pets and then the big one that medical schools really love your ideas, concerns and expectations. So, please don't forget. Um, and try and factor in when you're practicing getting this thing cos I know, I don't know if it's the same for Cardiff, but Sheffield, there's quite a few marks for asking this. Um And it was usually the one that people asked at the end. So it was the one you're most likely to run out of time before getting to, to ask. So try and get that one in. Um But essentially your ideas. So what does the patient or caregiver think is going on? Um What's worrying them? Currently, a lot of parents or adults even will Google and find worst case scenario. And actually when you drill down to it, um when the parents sort of being, if the parents sort of coming off, confrontational, not happy with what you're saying, trying to meet them as to what's going on or what they're worried about so that if you listen to and you can help either alleviate that worry or further investigate if it seems like a reasonable suggestion. Um So this kind of rare expectations get brought, brought in. Um, so what are they hoping comes from this consultation? Um, when you ask people, what, what are they hoping for? A lot of, some of the times they'll look at you like, well, I've come here to figure out what's going on. Um, but really it's to try and, um, understand where they're coming from and meet them halfway, like I was saying. So if a parent comes in with a child who's got a fever, um snotty nose and sore throat, um but they're bringing them in with the expectation that they want bloods doing and antibiotics giving, um then knowing that that's what they're wanting and then being able to sort of explain or reassure as to why if it looks more viral, that's not the best route to go down. Um It's really important in trying to make sure that you meet in the middle and know where each side is coming from and it leads to better outcomes for the consultation overall. So, um enough of my talking. So hopefully, that's kind of a good overview of um the history. Um before we go on to the case, is there anything that anyone wants to go back on in the history or has questions about um before we apply it to a case, was everyone quite happy, everyone's warning. Ok, fine. And so this is kind of a similar brief as to what you'd get. So for this case um oh, there's a question is heads good. And um uh so it will depend on the, um, it depend on the consultation um for the cases that I've seen less. So because you don't have the time to kind of delve in, however, I would be aware of it and know how to apply it because they very well could use a case where you'll need to apply a heads assessment for the most part when they're doing the history taking, it's making sure that you're doing the, the, the sections that are outlined. So make sure you're hitting birth history, immunizations, um development. Um All of those things, I'd say the more important ones to focus on, but I don't know. What do you think with Cardiff? Do you, is that something that would be relevant to the cases that Cardiff used? Yeah. Yeah, you can use it as long as you have a structure and you don't run out of time. Yeah. Um So I think making sure that you're applying it to the case that you're given. Um So don't get too bogged down in trying to just use that um because you might miss out on quite a few marks in the other areas. Um But yeah, is that all right? Um How do you approach safeguarding? How do you approach safeguarding in terms of asking the question? Mhm So, um so for me, if I'm, if I'm seeing a patient, I'm working through the booklet. So we have, er, Clark and booklets. I'll usually start by saying, so I get onto it and I'll say, um, so I'm just gonna ask a question. It can be quite sensitive. Um, but it's just something that we ask everybody, um, in order to, to complete uh, our history. Um, has there been any current or previous safeguarding issues um, that we need to be aware of, um, with any of your Children? Um, and usually people understand that you're asking it from, you're not pinpointing them as you think that they're, er, you're not sort of assuming that they've got a safeguarding thing. It's just part of the work up and the questions that we ask everybody who comes in. Um, I think it's the way that I do it but, um, I don't know, is there any other way you ask or? Um, sorry, I was just gonna type it up on, on the chart. Um, basically safeguarding. Um, I would say stick to the normal history and then if there is anything suspicious, so you can ask a bit more. Um, but the main thing is that you recognize it and let the examiner know at the end, um, you don't need to tell the parent that's not on you. Not the, no. So you wouldn't have. So it was the question, how do you ask about a safeguarding issue or how do you, how do you approach safeguarding? Ok. So if you had a safeguard. So, yeah, I don't think you'd have to do that in an exam if you're having to, you have to ask the question cos it's part of your social history in practice. Um, but you wouldn't be expected, you a senior would be involved in a discussion like that. So if you felt like you had safeguarded concerns about a patient that you were seeing, um, if it's me, I wouldn't broke the safeguarding with the parent directly. I'd just get the history about if there's been previous safeguarding concerns, um, or issues that we need to be aware of. Um, if they're coming in with a safeguarding issue, then I'd take the issue as I would normally and then I'd escalate to my senior that I had a concern and then the senior would take over from then, but I wouldn't, you wouldn't be expected, um, to deal with that on your own or to broach that in a oy, does that, ah, man, on the, um, yeah, he, he said it's a good, good idea to ask, um, any social workers or health visits involved. Yeah. Yeah. Um, so, yeah, your, your only job really in the history is collecting information. So you won't, you're not expecting to sort of raise the safeguarding concern to the parents. It's just to kind of collect, has there been previous, um, that we need to be aware of or current ongoing? Um, but, yeah, that's it really for the history side of things. Um and if you did have a safeguarding concern about a patient you were seeing then escalate to your senior um as appropriate. Is that all right? Yeah. Yeah. Ok. Um, so for this case, er, you're the on call F one at District General Hospital, you're in A&E and you are seeing an eight week old baby girl called Sophie who's come in with her mum, Sarah after being referred to pediatrics with a history of fever and vomiting. So please take a focused part history from Sophie's mum. The examiner will then stop you at seven minutes to ask you some questions relating to the case. So this would be what your sort of brief looks like. Um sort of and certainly in terms of our mo is, um, if you were coming in, um, in that time after you've read it, you'll be only be thinking what sort of things might is going through your head that you're going to be wanting to ask about. Um, so anyone got any ideas just to pop in the chat of what sort of things will be running through your mind after reading that brief that could be going on any seizures? Yeah. Uh gastrointestinal issue. Yeah. So, uh what sort of, so sort of are you thinking like gastroenteritis? Yeah. Is any of this or very quiet as it Monday? That's all right. We'll, we'll keep going. Um So what do you want to know. So, um so you, I, you've introduced yourself to the parent um and identified that you've got um the correct patient, Sophie, you're talking to Mum Sarah. Um What, how are you going to start the consultation? Anyone want to fire off a question about what they'd be asking mum next or what their first question would be bottle fed or breastfed? Yeah. So, II that is definitely one of my questions that I'll be getting to um a little bit before that. So if you first sat down with mum, what's your first question? That's going to open the consultation up or how long has it been going on? Yeah, perfect. They're all really good. These are all good for later on. So what I'm trying to get at is you're presenting complaints. So sort of your open questions. So starting off the consultation. So you said hi, my name's Kia. I'm one of the pediatric Sh Os. It's nice to meet you. Can I just check? This is Sophie. Mum will say yes. And are you mum check that? It is Mum and Sarah? So just say um so what can you tell me about what's brought you in today? Um And that opens up that open question that we were talking about, of presenting complaints. So mum would then say, well, I brought her in because I'm worried that she's got some fever, some vomiting and I just wanted to check it out cos I'm a bit concerned about it. So then you've done that open question. So, always start a consultation with a nice opening one. And then like you were all saying, in terms of the, the feeding et cetera, that's when you can start drilling down into your focusing er, the history a little bit. So for the history of presenting complaint, what sort of things are we wanting to know? So everyone does this a bit differently. Um I ask questions relating to the presenting complaint first. So I'll be asking questions relating to fever and vomiting and then start bringing in the additional symptoms after, but everyone does it a little bit different. Um So if you, what sort of questions it can be a bit of both if people find it that they don't do it this way. Um So systems review slash history a complaint. What sort of things are you wanting to know? How long? Ok. Yeah, bro, what color is a woman? Excellent. And that's trying to ascertain if it's bilious or not? Bilious? Brilliant. Yeah. Has the child's behavior changed at all? Yeah. Any diarrhea? Mhm. Is it constant fever? Does scalpel work? Excellent. Well, yeah. Are they sleeping? Mhm. That's really good. Well done guys. Um Well, so history complaints. So I always um ask what the temperature was. Um Sometimes parents will say they've got a fever but um when you actually asked and they just, and they felt warm, they never actually got a recordable temperature. So, um, that can be helpful, especially if, when they come in, they've not got a temperature and, um, and they never actually had a recorded one. So if this baby, hers is 39.4 and the mum took it from, er, under the armpit in the villa. Someone said about, when did it start? So the temperature started two days ago, someone else mentioned about Calpol. Does it work? So initially it was working, it was bringing it down but now it doesn't seem to be. Um, and then for the vomiting that was a day ago. Um and like someone said, color. So this is non bilious. Um So baby's just been having milk, so just milk that seems to be coming up, there's no blood in it, um, frequency of vomiting. So how many episodes have they had? Um, it's about six and I kind of add in is it projectile or not? Um, just so that if there's a, there happens to be a concurrent projectile, er, bit er, pyloric stenosis going on with er illness, then you don't miss that either. Um But yeah, so it's actually your history. So essentially when I do it, I try and aim the first few questions at the two or however many symptoms the childs come in with or adults come in with and then I branch out into my systems review. So um, so I start with the general. So looking at rashes, um, color of the baby, um, are irritable, er, any weight loss, any night sweats, any reduced feeding. And then you can, because at this point they've got a fever, we don't really know where it's coming from. Um, for this child, you probably do have to do a bit more of a systems review to try and figure out the source. Um, so respiratory wise, no, increased effort doesn't seem, seem to be any respiratory symptoms. Um, someone mentioned about diarrhea that's been fine. Um, and then reduced wet nappies. Uh, the urine's been quite concentrated, uh, no foul odor and no visible blood in the urine. And then from the neuro side, they're a bit more lethargic. They've not been interacting very much, er, they need to be woken for feeds. Um, there's not been any seizure activity and then, er, ent looking at the ears and throat that looks fine and as does M SK and that's looking for any sort of joint or, um, sort of potential bone source infections. Ok. Birth history. So we've kind of covered this, uh, already what sort of things we want to know in the birth history? Far away. Yeah. Weight gestation illnesses during pregnancy. Yeah. Well, so, um, mum didn't have any infections or anything but she did have gestational diabetes which was just diet controlled. Uh, she was born at 38 weeks, so she was, uh, 10 and normal during delivery. She was born in good conditions didn't need any resuscitation. She weighed 3.2 kg and there wasn't any neonatal concerns immunizations. Uh, so we want to know if she's up to date. Um, would she be due them? Does anyone know? Rough? I know it's a bit mean. Uh, if you don't, the immunization schedule, does anyone know if she'll have had any or should we do any imminently? She's eight weeks old. Pneumococcal. So, yeah. So next week. Yeah, so pneumococcal. Not quite yet, but she'll be due um, the rose virus men B and the, yeah, the hip and all those ones. So that would be due at eight weeks. So she's not yet had it. She was actually due them tomorrow. Um, so does anyone think she'll be able to have them tomorrow? Oh, I don't have to him or does it not really matter? No, no, no. Yeah. Perfect. Yeah, she won't be having them tomorrow. So I'll have to reschedule those. Um, fine and so developmental and growth. Um What sort of question, what question do we want to ask um, for these? Does anyone know what she'd be expected to be doing? Roughly? She's about eight weeks old. So does anyone know sort of from her, um, what she might be doing already? No worries, if not. Do you have your Red Book? Red Book? Yeah, perfect. So we can assess what her weight's been like since birth. See what she's doing at the moment. Yeah. Ok. So she'll actually be totally be smiling. Um, it starts out about 66 to 8 weeks. Um, startling loud noises. Um, she, she's gaining weight. She's progressing along the 50th centile. So that seems to be ok past medical history. So she's not got any, not on any admissions and no previous surgery, um, medications and allergy. Um, so she's been having Calpol I put here. It's a shame while she's been unwell. Um, and no allergies. Er, family history, what we wanted to know in family history. Oh, and so there isn't it seem to be anything. So we want to know if there's any, um, any sort of infections in the, in relatives. Um, I've actually got that in the social history. But, um, yeah, uh, there's probably not, it's probably a limited amount in this one for that's related to the history of cent complaint, to be honest. Um, so it's less relevant. Um, social history. Um, so what else do you want to know? I've shown you that one but anything else in the social history that we want to be asking? Social service involvement? Yeah. So for her, uh, I haven't put it in but she's, there's not been any safeguarding issues with her or her sibling. Ok. So both parents are nonsmokers. There's not any recent travel but her three year old brother is also unwell. He's got cough cold symptoms and he's attending nursery. So you might have got it from there. Ok. So further investigation. So you've got this little girl who you've taken this history from, you've collected some information. What are you gonna want to do next? Anyone got any ideas, stool sample, basic all this blood test. Yeah, perfect. Anything else that goes with history that you do follow in your history x-ray urine dip? Lovely. These are all very valid answers and the initial one that I'd probably be wanting to do is just to examine. So, um someone mentioned full observations. Um and then I'd be completing the examination to the history is not told us a huge amount as to where the infection is coming from. Um So in this baby, I'd be doing sort of a full um review. Uh generally looking at them having a listen to their chest, feeling their tummy, um looking at their ears and throat, um and then doing full observations. So, um these are the observations and examination findings. So she looks unwell. She's got mottled skin, she's pale lethargic, but she is Rous. She's not got any rashes, she's got a sunken anterior fontanel at the front. Uh her heart sounds are normal. Her chest sounds fine, abdomen is fine and these are her observations. So her temperature's 39 her heart rate's 100 and 70. Her respirate is 45 her fats are fine at 97 and her capillary refill time is three seconds. Um So if you want to jot, if so if you've got a pen and paper handy and you want to jot a couple of them down, it might be relevant to the next slide. I'm just gonna show you um something which will relate to these uh findings. Um So I'll give you a about 2030 seconds just to make a note. Ok? So this is the nice guide guidelines, but under fives with fever. So they do like a traffic light system. So they have green amber red. Um And obviously you're not gonna be expected to know or memorize this for your ki but they might show it to you. Um or it's good just to have an idea of what might be a red flag symptoms in a baby and when to escalate as well. Um So using the obs from the previous page, I'm just having a little look through this. Um I want you to have a look and see where you think this baby will fall, whether there'll be a red, an amber or a green um sort of risk. Um And then we'll have a bit of a chat about it on the next page. Um So obviously you can see in the green, a lot of the observations are OK. They're hydrated still. Um They still seem to be quite interactive, normal color and then the amber, the parents think they look a bit pale. Um They're not responding as much less smiley, um less interactive. Um They do have some increased work of breathing. Um Oxygen saturations are teetering a little bit below um a little bit tachycardic, some prolonged cap refill. Um They look a bit dehydrated dry mucous membranes, feeding less reduced output. Um And then in your other, you've got your fever um between your three and six months old, if you've got a fever of grace for a week, equal to 39 and then you've got your red wrist, which um obviously, if the clinic, the clinician thinks the child looks pale or mottled, then it escalates it to red. Um The interesting thing in this is, you know, the child could have all amber sort of tachycardia respiratory rate. But if the healthcare professional thinks that the child looks ill, that immediately escalates it to a red, which was quite interesting. So it obviously, you know, figures are important, but actually assessing a general examination is really important um to not to always just rely on the figures. Um So hopefully you'll have got an idea of where you'll be putting this baby on this wri on this level. So the three things I want to ask are, what traffic like color would you assign to this baby? What condition are you now most concerned about with this baby? And what management would you want to commence? Um So if we start with the traffic light color, if you pop in the chat, whether you think there'd be a green, an amber or a red and see what people think red. Yeah. Yeah. So, I would agree with that. So, I'm putting them at red and on the next page, I'll go back to the observations and show you which ones were amber and which ones are red. Um, essentially that traffic light system is more used in, it's more for community and when they refer in, but we do use it in clinical practice when we're assessing Children um on the walls to see what their score system is. Um And whether they're sort of thinking they've got a more severe infection going on. Um But yeah, um it is, it's a good, it's a good one just to be aware of. Um So what condition do you think this baby might have or what are you concerned about at this moment in time? Pop it in the chat if you've got any sort of suggestions? Substance? Lovely. Perfect. So, yeah, so I'd agree, I'd say sepsis with possible shock. Um And then I wouldn't, at this moment in time, I wouldn't say we know what the infection origin is. Um We know they've got fever and vomiting but in a baby they're difficult to know they can't tell us where is hurting or um where might be causing them issues. So, um so yeah, but I immediately be thinking sepsis uh based on the examination findings. Um and all of that. So in that case, what management do you want? To commence or what would be your initial sort of plan admin, admin be same day sepsis. A broad Bactrim antibiotics. Perfect. Well done. So I'd be doing, I know you've already done technically, um the history uh the examination and observation on the previous page, but I'd still say a to e assessment. Um, it shows that you were that clinical pictures can change and you would be reassessing the situation. So ABCD e referring to a senior pediatrician. So you'd be getting a senior as help with this and escalating it. Um And then, yeah, absolutely. Right. Sepsis six. So everyone's got different ways of remembering there. Some three in three out. I remember it as buffalo. So um B for blood cultures I've added in blood and blood gas there cos that's the other things we'll do. You monitoring the urine output, uh fluids, IV antibiotics, IV lactate and then oxygen if needed. Um And in this baby being only eight weeks old, the other things that I would be thinking as well is urine culture and lumbar puncture. Um So yes, so just to go back to that observation and examination. So these are color coded. So the looking unwell mottled skin and pallor would be in your red category, the lethargic, but ras wall is in your amber sunken anterior fontanel wasn't specifically in there, but it's kind of along the same lines as the reduced skin turgor. So I popped it in the red um these were all fine. Um And then temperature because she's only eight weeks old, she's less than three months. And so if they've got a temperature over 38 immediately puts them into the red. Um, heart rate is quite tachy cardi cos that scores are in amber and the capillary refill time is also in amber. Um And then going back to the history, um the reduced feeds and the reduced urine output, um, less interactive would all have scored her Amber. Um for that lovely. So, um, in the IY series, they've come up with a quite a nice way of doing the further investigations, obviously with the sepsis. The main thing I want you to get across the examiner is that you're gonna be safe and that you are sort of assessing an acute young male child with a escalating and sepsis six. But then once you've kind of said that you can add in any further investigations, um, if you've got time as well, uh some of which you've already discussed. So your bedside ones, uh we've already mentioned your full systems exam observations. Um And then I guess these ones kind of could come under the o for the orifices, but I pop them in bedside because it's things we'll do uh when we're seeing the child at the time, but urinalysis, um plus or minus urine culture, er, viral swab, stool culture, bacterial throat swab. Some of those have been mentioned throughout the session which is really good that you're all thinking of that. Um And then bloods anyone got any ideas of what bloods we wanting to send for this baby? Uh Do you see any? Yeah and CRP and LFT. Lovely. All done. So yeah, so your F ECC RP is looking for your infection markers. Um you and S um su success and dehydration any AK I from um ANP shock uh LFT S um blood glucose would come on your blood gas as well, but it's um it's good to have one of those, especially if you're doing a lumbar puncture. So you can compare the glucose to the glucose in the CSF um and then your blood cultures um in Children, we do either venous or capillary, um venous if we popping the cannula and you can take it at the same time. Um But obviously you can't interpret things like the oxygen uh the po two, but the capillary blood gas you can. Um So if you're concerned um about a child's uh oxygenation, um if they're needing respiratory support, then you'd be doing a capillary blood cath er imaging. Um So this er is more general but some of them been mentioned, uh what sort of imaging might you be looking at doing er for this child? You've mentioned a few of them. No instructions. No. All right. So imaging. So chest X ray, if the child has respiratory signs, if you're wanting to look at um, possible pneumonia, um, abdominal ultrasound scans for appendicitis or in certain situations for uti, um, we, we'll come onto that later on. Um, and then CT scan if indicated. So, if you think of meningitis, if you don't routinely do a CT scan, um, unless you're wanting to do a pre lumbar puncture, um, to assess so raise intracranial pressure. Um, but yeah, that's something to consider. Um, ECG is just part of the, the boxes sort of er acronym, but I wouldn't be rushing to do one in this baby. Um But it's just something to be aware of uh when assessing other patients. Um and special tests, anything. So we've mentioned it on the last slide, but what else do we want to do in this baby? Uh What other investigation that's not already listed on the screen? LP? Yeah, lovely. So your lumbar puncture. So unless you're looking at your CSF, so you can culture that. Um and then you will also send like when you're doing the bloods uh the meningococcal pneumococcal PCR and that's a blood test that will get sent off. Um And then they can do the viral PCR from the CSF um which uh looks at three in particular, which listed there. OK. So these are the investigation results for this little girl. Um So don't worry in the ki you won't get given all the sets of investigation, I'm gonna give you, but it's just useful to kind of cover them, um, for this purpose. So, um, does anyone want to highlight what might stand out? Are these bugs normal? Are they not normal? Um, anyone want to pop in the chat? What they think? C RP high white blood cell count? High CRP high. Yeah, lovely. Um, so obviously I've not popped it on here but like you would, with every investigation in, if you're given it in the Iski, um, identifying, um, what sample you've got. Um So these blood tests from this date at this time, um it would be, it would say it in the iski but saying it out loud, the examine nose and then identifying the patient that they belong to. Um But yeah, you're absolutely right. So CRP is really quite high um cut offs usually like less than five is normal and then above that, um the higher it is, the more in general we worry um white cell count is very high, neutrophils, very high lactate is also high. Um I think on a gas, the cut off is about two. So, um yeah, uh it could be dehydration, it could be sepsis related. Um And then the creatinine is also quite high um showing that they're quite dry, which could be the dehydration from the vomiting, but it could be cusp shock which is causing uh hypoperfusion. Um Next one, we've got urine dip. So, does anyone want to see what they think that shows would be treated as a UTI based off that or no. Yes, lovely. So you'd send it for a urine MC Ns. Agreed. No, you wouldn't. No. Um ok. So um let's go through it. So you've got your erythrocytes are one plus leucocytes are negative but your nitrites are positive. So it's not um sort of your bond or, or positive. Um but we would treat this as a uti um until sort of proven otherwise. So, in this case, we would send it for your own MC Ns and wait for the result to come back. Um And in under three month olds, you just send the urine MC Ns anyway. Um So yeah. Um so in this case, you would send the MC Ns in which case, when we get that result back, it's E coli positive. Um And then our lumbar puncture results come back as well. It's a really good lab there. So you get them all back, right? Nice and quickly. Um Anyone wants to talk me through what the lumbar puncture is looking like. Is it looking normal or abnormal, normal? Lovely, well done. Um Yeah, so it is, so obviously in the exam, um I know it's difficult in this setting, uh going through it like one by one sort of reading it out and sort of saying that's normal, that's not what. And so the exam knows exactly what's going through your, um your head, but you're absolutely spot on it is normal and then your blood culture was also e coli positive. So anyone wants to pop what they think the diagnosis is based off our collective picture. Yeah, it does urosepsis, pyelonephritis, urosepsis, e coli. Lovely. So you're absolutely right. U apsis um which like someone said, it can be from upper or lower um cause. So yeah, uh spot on but yeah, U apsis. So just a quick recap on the definition of sepsis. So it's a life threatening condition that happens when the body's immune system has an extreme response to the infection. In this case, the uti which then causes the organ dysfunction that we've seen with this little one. So just to quickly go over UTI S um with you. So this one, so there's two sort of categories. You've got your lower and your upper, your lower affects your bladder and your urethra and your up, there's more ureal pelvis in your kidneys. Um And then we more see in, you'll probably more associate asymptomatic bacter bacter urea in um sort of the elderly population, which is sort of where they have bacteria in the urine. But um without the signs and symptoms of the uti that we'd expect to see. So I was gonna ask you what the main cause is. Um but it's already come up. So main cause in Children is E coli. So it's about 85 to 90% of um uti causes of that. Anyone know of any others that um cause uti I, no worries, if not. Um, the other one that we can see in, um, which more affects, er, boys if they're uncircumcised with the proteus, er, one. but yeah, your E coli is the mainstay one that we need to be aware of. Um, so this is just a quick overview of dipstick. Um I wouldn't stress about this. It was just sort of more interesting to look at your dipstick results and when you investigate or treat so, um your leukocytes and nitrites positive um in both three months to three years and over three years, you would assume and treat as a uti um and send an MC NS um in a three year old, it would be more if they're thinking they've got a high risk of a serious illness. And then like we've seen with this little one, the leucocyte negative and nitrite positive. In both cases, you treat it as a uti um and then wait for the urine M CNS to come back um to determine further management. Um if you're seeing leukocyte positive, but the nitrites negative, um this is where it starts to change. So, between three months and three years, um you treat it as a uti and send a urine M CNS. Um But in an over three year old, if the nitrites negative and it's just the leukocytes are positive, then you only start antibiotics. If you're thinking if there's actually symptoms or clinical evidence of it. Um And then you wait for the M CNF before starting any treatment and if they're both negative, then it's highly, highly unlikely. It's a UTI and you need to be looking at um another differential. Um The only times you really send the M CNS, I'll put the little stars there. Um, is sort of, if you think if they've got recurrent uti S, if you're thinking that clinically, they actually do have a UTI, even if the Dipstick has been negative, if they've got pyelonephritis or you're thinking they've got pyelonephritis, then you send it anyway. But yeah, it means is that it's much less likely. Um So this is your ages. So if they're less than three months, like this little one was, um, you refer them urgently um into secondary care, er, you get a urine MC NS and they will, if you're thinking they've got a UTI, then they will start parenteral. You don't go down the oral route if they're less than three months. Um, likely because in the under three months, if they have a fever, um, it's usually because there's more severe infection going on. So they tend to err on the side of caution and treat it as such. Um, if they're over three months and an upper um dipstick, it's depending on clinical picture. You can refer. Um, but if they're well on themselves, then you can consider oral antibiotics. Keflex and being your main one. Um, Coamoxiclav is another one, but that's more if you've got the culture results back um already and it's sensitive to that. Um However, you've got all trusts will have their own guidelines. This is the nice guidelines. Um But in a case of an iski, if somebody's asking you um about treatment, I'd say first and foremost, I'd follow the trust guidelines. That is the hospital I'm working at. Um And then if you've got an example of what you know, is commonly treats, then you can give an example. One. and then reassess the symptoms worsen, um, or don't improve in 48 hours because it might be that it's resistant. Um, it could be that it's spread. Um, and it's actually a more severe infection than what can be treated by oral and the IV. Um, and then for lower, you usually don't need to be seen if they're, well, it's just oral antibiotics and dipstick and then assess them and make sure that they're improving and you can, er, ultrasound is indicated in some Children. So if they have got an atypical infection, which is this, um, then you would get an ultrasound in the current acute infection stage. Um, so in this baby, do we think we'd get the ultrasound? Have they got any of those that would mean that we need to get the ultrasound? No one's answering. What was that? Sorry? No. Ok. Um, so th this little 11 of the atypical UTI criteria is sepsis. So, um because she were thinking she was Europs, um Also, does anyone remember the creatinine was a little bit on the high side? Um So for this little one, we probably, we would get one just to during the acute one. just cos she's got a couple of the et IC the atypical criteria on there. Um And then within six weeks we get an ultrasound if they're less than six months with the first time and it's responded well, um or if it's a child or baby with a uti that's not E coli but it responds to treatment. So they're the ones that you doesn't need to be done urgently, but we would be looking to get it to make sure there's not anything untoward like structural um going on. Um And obviously, if the imaging is abnormal, then we'd prefer so causes a fever. Um So this is just sort of an overview. Um It's obviously not all inclusive. Um but it's just sort of some, not so common but ones to be aware of. Um So your bacterial, um you've got probably ones that you will recognize quite a lot on there. Um And then your viral going through, especially this time of year, you've got your RSV, which causes bronchiolitis. It's quite a common one. Um your group, which is parainfluenza. Um So they're sort of other things you might be thinking of. There was a bit of a red herring and the, the brother had a cough, cold symptoms. Um, but it's important because of her age as well. Not, it might well be that she had a viral infection going on as well. Um, but if we'd assumed that I'm not investigating her, we wouldn't have found the UTI, so it's always kind of keeping you over the bigger picture. Um, and uh sort of making sure we don't just focus on one thing. Um and then inflammatory Kawasaki. So if they've got a fever for more than five days, um polymorphous rash, um conjunctivitis, um you're starting to think Kawasaki. Um They love asking that in exams, more written. Um And so just having an, an idea about that just because um with that particular condition, um one of the complications is coronary aneurysm. So, with these Children, once they're identified, they'll need to be on um aspirin and uh have echo and follow up arranged. Um but yeah, and then your other, so your leukemia lymphomas, obviously with a two day history of fever, I'm not jumping to these type of ones, but it's just having an idea of if there's prolonged fever or it's not quite fitting symptom wise. Um Just wants to consider um and travel abroad for malaria vaccine induced. So, if she just had her vaccinations, um obviously, we'd still rule out other causes of infection, but sometimes they can have a sort of low grade fever. Um after having that and be a bit more lethargic and sort of not as well in themselves afterwards. Um This is just a general, um, sort of as to the reason why she was, she was only eight weeks old as to why she was indicated for like a lumbar puncture and that kind of thing. Um So obviously, if they're less than three months, we were worried that they've got a severe infection. So it's vital signs doing that first. Um Like we did sort of the full blood count, blood culture crp um urine testing. Um and then stool and chest X ray if, if relevant. Um and then in deciding who gets a lumbar puncture. If they're less than a month, then they automatically do or should. Um In her case, she's 1 to 3 months, but she looked and, well, so that's um her lumbar puncture as well as um her white blood cell count being really high. Um Obviously, it shouldn't delay the giving of antibiotics. So if it's gonna delay it, the antibiotics should be given in the lower point are done at the earliest convenience. Um But ideally if we can do it before antibiotics and that's um appropriate. Um and then an antibiotic. So it's the same sort of criteria as the lumbar puncture. Um in terms of which ones you'd give, if they're less than three months, then you'd be giving a third generation um cephalosporin and then you want to be adding on er, cover against asteria as well. Um, just some other ones that, um, we've mainly covered fever, which is quite a common presentation but just some other ones, geeky medics and stop for some really good examples, um, for sort of further information. So sort of further reading, um, practicing some of the cases with your, um, colleagues, um, and sort of honing in on that history. Um, but yeah, your abdominal pain, um, some of the different ones that can cause it. Um it not just abdominal causes but also like your endocrine like DKA, um lower lobe pneumonia can sometimes be referred and Children aren't very good at always good at saying exactly where. So it could be that as well. So making sure we don't miss it, um testicular torsion. So in, in Children, making sure we examine the testes um or saying that you would um examine them to make sure that you're not missing that and then your breathing difficulties, your, your wheeze ones are more your bronchiolitis viral wheeze asthma. Um pneumonia is more your difficulty breathing, low sats, um crackles and then you croup inhaled foreign body and epiglottitis via Strida and uh difficulty breathing and then things like childhood bruising. So sometimes petite purpura can look like a bruise and bruising can look like those. So it's sort of having a good wide differential. So na I is not accidental injury. Um Sometimes it can be accidental injury, but establishing the story which one does it fit with? Um, is it a, is it a realistic mechanism of an injury or not? Is it soft tissue that's been uh bruised or is it on a bony prominence? Um HSP. So they're more likely to have sort of joint pain, uh, might have some kidney involvement, abdominal pain can come along with it. Um, and I tend to have a rash from sort of buttocks and lower limb that's purpuric um itp um that can develop you sort of post, post illness and as we see that and that's monitored, um but again, they'll come out in a purpuric rash, it's quite fast spreading meningococcal septicemia, which is also one not to miss um leukemia and coagulation disorders. Um Obviously, that's just an overview of some presentations, but just having an idea of um sort of your differential and things that you want to be ruling out in the history is always quite good going into it. Um But yeah, um so that's sort of hopefully a overview of the history. Um It might feel a bit overwhelming, quite a lot of information and some of it's more um sort of in your clinical practice um and picking how much detail you go into with it. Um But as I said, with the birth history and sort of developmental, just asking sort of the standard question um is probably sufficient enough rather than having to go into all the nitty gritty. But um in clinical practice, it's useful to be aware of it as well. Um, and then you can hone in from there, but hopefully that was ok. Um, but if anyone's got any questions, then feel free to pop it in the chat. Um, and I'll try our best to answer them. Um, how do you practically go over getting a urine sample from an eight week old? Yeah. So, um, so it's easier said than done. Granted. Um So there's a few different methods. So sometimes if you're wanting a clean catch, we literally get um a uh a sort of container and you sit the baby on it. Um, if it's a female, you'll just sit her on and wait for her to have a weight if it's a boy. Um, you kind of do the same but it's a bit easier to kind of maneuver the, the box underneath them. Um But yeah, it's uh it is tricky. Um, but it, you can do that. Um That's if you want a clean cap and you wanted to send it off for M CNS because you need it to be er reliable. Um, as opposed to touching the skin if you're just needing it for a urine dip, um, you can put a bag um over the genitalia and it sort of collects the urine when they have a wee. Um, however, it's not as reliable. Um, obviously cos it can mix with um bacteria from the back passage um, but that's quite a quick way of getting urine dip. And the other one is you can put cotton, er, you can sort of put um, a pad in the nappy if you're wanting just for a urine dip. Um, and then again, that's not reliable for a urine culture. Um, but you can basically squeeze it out and collect a urine sample from that. So that's few urine dips and for a culture it needs to be a clean catch. So essentially just sitting the baby on a pot and waiting for them to have a weed is how we'd, we'd go about it, but it shouldn't delay the treatment of it, shouldn't delay the giving of antibiotics. So, um obviously, if we're able to do great, but um they should be having antibiotics and then try and catch it afterwards. If not any other questions, I'll stop sharing so I can join. I thank you, Kiara. Um If you guys could kindly do the feedback form, so we know where to improve would really appreciate it. And next week, uh we'll email you if you're on the um mailing list. Um We'll, yeah, we'll probably have one more session next week and then we'll have our um hybrid uh examination session coming up. Thank you all for joining. Um I hope it was useful. But um but yeah, we I'll probably see some of you at the other mock is um But yeah, if, if you have any questions as well that you think of afterwards, um feel free to just email and um I'm sure I'll pick it up and I can try and reply as best I can. All right, that's our email if you need or you can message us or next day as well. Yeah. All right, you do. Ok. Thank you guys. If you don't have any questions, um I'm gonna stop the session. Thank you for coming again. Thanks. You guys take care.