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Just lay down. Ok. Hi. I thank you for joining us on Tuesday evening. So today we have Doctor Georgia Pierce with us doing a lecture on the lip child and neurological conditions of pediatrics. So, um, yeah, if you have any questions, pop them into the chat and I'll hand over to Doctor Pierce. Hi. Uh, thank you for that introduction. Um Hopefully you can all see the sides. Um So today we'll be running through uh limping child and neurological conditions. Uh So my name's Georgia. Um I'm currently in F two at West Middlesex. Um I'm on pediatrics actually, I've been on there since December and I'm gonna be on there until the first of April. So I think you guys are just rotating based on the conversation I've just had. Um, so if anyone is on pediatrics at Westmead, feel free to uh come find me. I'm happy to talk to you about anything or discuss any of your sign offs or anything that you need doing. So, yeah, more than happy for anyone to come find me and if not, my email is there as well. Anyone feel free to email me about any fifth year stuff or any pediatric stuff or any foundation. Yeah. Just anything, like, feel free. All right. Um, so what we're gonna do is go through some different conditions. We'll start with doing a bit cases. Like we'll do a little case, then we'll go through some S PA S and then we'll go through, um, the actual content usually. I mean, I used to not like people, um, asking for interaction. I know sometimes it's difficult, especially when a lot of you watch this as a recording instead. So what I would encourage is that you just interact in your own way when we go through some of the cases, just think out loud wherever you are or write down whatever answers you think might be relevant or answer to the question because that way you will get something out of it a lot more than if you just sit and watch. This is like a boring lecture. So hopefully it won't be. Um So we're gonna go through the limping child first and these are the, some of the conditions that are probably important for you to be aware of. Um And the ones in red are probably the more important ones. Um And then just highlighting on the right here, the difference in the bones between a child and an adult. Um So the child has the uh thesis between the uh metopus and the epiphysis, uh which is their growth plate and this will be reflected on some of the x rays that you'll see, there'll be huge gaps and that's just where the growth plate is. There's nothing broken in the bones. All right. So if we go through the first case, I think this might be the only case in this, uh presentation. So if you're the F one in a, a and you've got a four year old child presenting with a right sided, painful limp and they're unable to wait there for the past two days. And they're also febrile. What I need to do is think about you the F one, this might be the scenario in your actual final er, cases rather. What key things do you want from the history, what key things are you going to examine? Like, how are you gonna structure your examination? What are you gonna do? What red flags do you need to make sure you rule out either in the history or the examination? And then how are you gonna manage this station? Obviously, we all know the bedside bloods imaging. I also think MDT is really important. What other people are you gonna involve? And I think just saying that you do an MDT approach involving certain specialties that will put you against other candidates really well. Ok. So if you just all, I don't know, take a minute in your own um to think about these answers and then we'll go through it in about a minute's time if that works if anyone has any questions throughout, um, feel free to put them in the chat or you can email me after. That's absolutely fine. I can't see the chat but I think, uh, the med Ed organizers are gonna let me know if there is any questions. So let me give you about a minute and then we'll, we'll talk through. Ok. Uh, hopefully that was a minute. I didn't really time it. Um, but hopefully you've come up with some answers at least. So we'll go through them now. So this is what's really important to cover as you go through. So in terms of your history, when we were thinking about a limp, it's really important to just be super nosy. So think about how long has the limp been there? Was there anything that caused the limp, especially looking for any trauma? And if there is trauma, does that trauma make sense for the injury that they have? So thinking about, could this be non accidental injury as well? Are they able to wait there? So are they able to walk on that limb? Um And then if it's painful talking through your Socrates? So I'm sure you will know this from third year but going through where it is, how quickly the pain came on, what type of pain it is? Does it move anywhere? Is there any other symptoms associated? Does it get worse? Certain times of the day? Anything that makes it worse? Um, and the severity of it. And obviously, depending on how old the child is, they won't be able to answer these questions or you might have to modify some of your questions to an easier understanding of the child, you know, um and then going through your flaws as well. So is there any systemic symptoms that could be contributing to thinking about more of hematological diseases here? And then, is there any preceding illnesses, Have they been ill recently? Have they been in contact with anyone at school or nursery or whatever they are? And another thing is key, is there any antibiotic use because that might mask any fevers that they've been having or they might be recovering and coming out the other end of an illness? Ok. So hopefully you had some of those answers in terms of examination. It's obviously important to get your full set of observations. Um And the way you approach a joint would be the look, feel, move. So for instance, if you think the pain's coming from the hip and that's what's causing the limp, you have a look at the hip, see if there's any obvious swellings, any redness. If there's any scars, any obvious deformities, anything like that have a feel of the joint, feel like for things like temperature, any cramps or if they're able to passively and actively move the joint as well. Ok. And then often you can, it's important to just say I would examine the joint above and below. When we're thinking of the hip, you would examine the lower back, like lower spine. So you may maybe do part of your gauze examination with that and then obviously the knees below that. Um And then if the diagnosis isn't clear or maybe you're not convinced this is something from say the hip. It's always important to consider other diagnosis and maybe you would do a full examination of the back or the abdomen or a testicular examination as well. Ok. And these are some really important red flags that you have to pick on and not miss as well. So if the child, if the history has been over 48 hours, if they're non weight bearing, if they're febrile any night, pain, systemic illness, if they're under one or over nine, it's a bit suspicious as to what's causing this. If there's any clear abnormality on the exam or any unexplained bruisings or rashes. And then in terms of your management plan, hopefully you've all been able to come up with a few little ideas. So your bedside is basically your above examination, plus maybe a urine dip. I'm sure there's some that I have missed doing this. Um and your bloods, what's really important when you're thinking a limp is CRP and ESR. So they'll tell you the difference between an acute and chronic inflammation and blood cultures as well. And then imaging, you're thinking maybe X ray, ultrasound, potentially MRI and then MDT, the key ones that are going to be really here are orthopedics, obviously, infectious diseases and micro, especially if you're thinking prolonged antibiotic duration, maybe things like physiotherapy. Um And if the child doesn't have to stay in hospital for a long time, you can think about um the hospital. So the school at hospital which are like teachers that come in and they work through workbooks and things like that with the kids. Ok. So this is just um, one of our guidelines actually from the trust that we have on how to approach this. So this hopefully will give you a good approach during your paces that you can work through. So, is there a clear history of a trauma? Yeah, you're probably gonna want to x ray it. If there's no history of a trauma, then you work through those red flags. What else is going on? If there's no red flags present, you can be likely to reassure the patient, give them some conservative management, you know, rest nsaids, paracetamol, um Nurofen in that case and then rereview if it's ongoing or if there's any worsening, you safe to let them to come back. If there is red flags present, you may think about doing these further investigations that we just talked through. Um, and then the key thing will be based on those investigations. If they're all negative again, you might discharge home. Um, but if they're positive, you may start thinking about what is the diagnosis here and who needs to be seeing them. So, any child that presents with a limp really needs to be seen with no obvious cause needs to be seen by the pediatric team. So this is whether you're in a GP setting or whether you're in an A and a team. Um because remember in A&E, there's a A&E team and there's a pediatric A&E team. So there's a.