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Hello. Can you hear me? Uh Yeah, I can. Hello? Can you hear me? Yes. Can you hear me? Oh, sorry, I can hear you now. Yeah. Um What's the problem? The, the speaker doesn't have the option to turn the camera on the speaker's not on here. She needs to join the actual Cool. Can you tell her to click on join? Um Oh, she's here. She, but she's not on the stage. She needs to join the stage. Um, Doctor Rao, you need to join the stage. You should have the option. Are you joining with the med account that we sent, uh the speaker invite to that, that you need to be careful with that. Um I forwarded it. Um, let's have a look, speakers and moderators, nitty ra unverified. That's probably why have you verified your email? So let me re add you. What's the email? If you just put it on chat, I'll resend it. Basically it says on here that it's unverified. Um What's the E email for N Oh yeah, I'll type it. Oh, full name 94 at hotmail.com. And you're sure that there's a med account attached to it, right? OK. Now try it. So, Doctor Rao, if you leave this call and then rejoin it, you should have the access to join the stage. Yeah, sorry guys. Um technical difficulty. Just give us like three minutes. We get it sorted, don't worry. Oh, perfect. There we go finally. All right, doctor, can you present now if you present now? Uh Yes. One sec. Let me just uh how do you share your screen on this thing? Um You know where your camera is? The next icon? It says present now um then you can click on share entire screen and then you'll share the entire screen where is present now. Um So you know how on the bottom of the screen there's turn on microphone, turn on camera present now, more options. Oh yeah, but it only says share PDF. Really? Yeah, it only, yeah, that's the only option. It's not showing share entire screen. No, I've only got share PDF. That's the only thing that shows. OK, Niharika, can you share your screen and then you can just flick through the next images? So you know the next slide, sorry. And that that can work then in the meantime. Sure. Um I'll have a look. Yeah, just, just load it up, staring up. Perfect. There we go. And then yeah, that can work then. All right, if you have any further issues, uh feel free to just message me. I'll hop back on there. Thanks. Cool. Thanks for your help hold one sec. That was unnecessarily complicated. Apologies. I might have you wanna feel free to start? Yeah, let's go for it. Ok. Do you wanna introduce yourself? Oh, have we started? Oh yeah. Can you see my screen? Yeah, I can see your screen. Amazing. Ok, great. Um hi everyone can, can everyone hear me? Are you able to read the chart? Uh No, me neither cause I can only see my screen. Um I think just continue. Ok. Yeah, that's fine. Yeah, I can read the chart. There are people there. Great. Um Hi, everyone. Sorry about the technical difficulties. We had a bit of issues there but hopefully everything will be fine. Now. Uh My name is Libby, I'm ast two in pediatrics at the children's hospital at the moment. Um and I quite like humanitarian medicine, so I quite like general pediatrics. So II graduated from Samu University in Budapest and I've also got a um post graduate certificate in public health and global health. And I'm working on a really fun project in the Philippines to build a mobile clinic for Children in different schools around the area. So today I'm gonna be presenting on uh general pediatric conditions and uh we'll start with this one and obviously it says the answer there already. But um I really wanna make this as interactive as possible because otherwise it's gonna get super boring for, for me and for you. So let, let's um let's try and put as much as we can in the chat. Ok. So the first case, I've got a few cases to go through and just like a bit of information about each one. So, um, a four month old boy comes to P AU, the pediatric assessment unit with a history of three days of cough and it's mainly when he's lying on his back and there are upper prescription noises. So, before we go on to the next slide, can you please tell me what you're going to ask the parents with? If you've just got this information, can you come up with some questions that you would want to know from the parents? You can just pop it in the chat. Yeah. Temperature. That's a really good one. Anything else? Yeah, feeds really important. Anything else? So with the feeds you wanna know what's been going in, you also want to know what's been coming out as well. So, what would you ask? Yeah. Mucus. Ok. Let's go to the next slide. Can have a look at that. So any other symptoms, cough, cold, runny nose, um, fever, like what we said, uh, vomiting, diarrhea or any wet, uh, how many wet nappies, um, feeding also? I forgot to put on them. Yeah, bladder and bowel habit changes. Yeah. So any diarrhea, we would also look at wet and dirty nappies as well. Um Just to see if he's wheezing to see if he's dehydrated. Ok. So, all of these things are quite important. Um, is there anything else that you want to ask them? Which I probably, I think I've just forgotten to mention one more thing about the cough and cold and runny nose. Would you want to ask anything else? So, I would probably ask if, um, anyone else is unwell at home as well if any siblings or parents or grandparents or anything like that had a bit of a cough and cold and runny nose, especially at this time of the year. We've got. So like the entire hospital is basically filled with the bronchiolitis babies. So um this is the time when everyone gets viruses and things like that. So um it's probably important to ask if they've been exposed to anyone else who's been unwell. Ok, let's go to the next one. So if you, you would als you would always ask about birth history and social history with um with any child who comes in that you're clerking. So, with this one, we've got um 39 plus three, which is pretty much term. It's an elective C section because mum had previous c sections in the past and just a history of um a couple of days of jaundice, which they've recovered from social history. Um He lives with mum, dad and his big brother who's two and um there's no social services involvement. So here are the obs and examination. So respiratory rate is quite high cos he's only three months old. Heart rate also is quite high. He does have a temperature of 38.5. His BP, this is normal for this age. Um, oxygen is 85%. So when you look at him, he's got moderately increased work of breathing with subcostal and intercostal recessions and a tiny bit of tracheal tug. He's um well perfused though with the cap refill time of less than two seconds and he is active and alert. He's moving around and he's crying, you can feel the femoral pulses quite well. And the chest and heart sounds are normal and the abdomen is also normal and there's no organomegaly. So, um, what would you do before we move on to the next slide? What would you do? So, what are the things that are concerning you at the moment? Yeah, definitely. Give oxygen coats are quite low at 85%. Anything else? What else is abnormal that we can probably fix? Yeah. Exactly. Paracetamol for the temperature. That's right. So oxygen and paracetamol are pretty important. Let's move on to the next one. Yeah. So with bronchiolitis, it's mainly supportive management. So you got that. Exactly right. Give oxygen and paracetamol. Um and then we'll probably just review cos the SATS did drop pretty low. So we would see what type of oxygen that we would need, whether it's low flow or high flow or whether we need to escalate to CPAP and all of that. But that's a, that's a different talk for a different day. Ok. So, um there's a bit of, there's quite a bit of text on this one. I'm sorry about that, but bronchiolitis is normally, it is very, very common. Um And we see it quite a lot because of inflammation and mucus build up. Uh So it's normally uh before one year and it kind of peaks at around 3 to 6 months. So, especially now in winter, you have quite a lot of a case of bronchiolitis and it usually lasts between 7 to 10 days. So this one is, is usually caused by R SV. So we wouldn't give um antibiotics unless we're acquiring um a pneumonia, a bacterial infection. Um And so they would be very, very sick if, if they had a bacterial infection on top of bronchiolitis, in that case, we would probably do a chest X ray to have a look if there's any x-ray changes. And so the reason for um a really good history is if they've got chronic lung disease, um, you know, if they were very premature, they might have chronic lung disease, um, you have to ask about if there's any heart problems, um, or any kind of other issues that we're not really aware of. And so with the symptoms, you've got a cough, a bit of a wheeze or shortness of breath and you've got a fever, runny nose, you know, all of that type of thing, poor feeding. And, um, if, if they're really, really not feeling very well, they might be quite dehydrated. In that case, we would probably give some IV fluids. So, with the, um, examination, you might find a bit of a wheeze, there'll be breathing really fast with tachycardia and a low grade fever. They may have a prolonged pre refill time and, you know, cyanosis and things like that. But that means that they're really, really unwell at that point. And so you, yeah, you have to think about pneumonia. If there's any types of other viral infections that could cause this um with the difficulty breathing or if they've got apneas, you might think about good um foreign body aspiration. Probably not at this age because they're really little. But maybe if they're a bit older, you might think about that as well. And yeah, chronic heart disease. And so with the diagnosis, it's purely clinical. So they've got um kind of cough and cold for about three days with a persistent cough. Um, and uh chest recessions and tachypnea with a wheeze and crackles and auscultation. And so we basically just have a look at the oxygen saturations and make sure that they're maintaining their oxygen. We have a look at their work of breathing. Um If they're struggling a lot, we might help them out a little bit with the, the trickle of oxygen. You don't really do do chest x rays if you're quite confident that it is bronchiolitis. But if you, like I said, if, if you are querying, if it's a pneumonia or something else, you might have a look if they're disproportionately unwell to what the diagnosis is, you might have a look at their chest. And so, yes, you just give them oxygen if it's below 92% and you help them with feeding as well. Um, if they're not feeding very well because they've got um low saturations or if they're working pretty hard, we might put a NG tube down to help with that. Um Just so that they don't have to work as hard to feed cos you know, babies get very excited when they, when they're feeding. So just to help a little bit with that. And so with the complications of this, obviously, um you've got dehydration, uh si A DH and hyponatremia, they're very dehydrated apneas and um they can get very unwell with respiratory failure. So it's pretty important to spot this quite quickly and just to spot low saturations and very increased work of breathing. OK. So that was the first one and um now we'll move on to the second case and so we've got a five year old girl. Uh sorry, does anybody have any questions about this or should we do questions at the end or should we, if anyone's got any questions in the middle, just uh feel free to pop it in the chart and then we can go through it. I might be going a little bit faster, just let me know. Ok, so we'll go on to the second case now, which is a five year old girl who came to Ed because of her fever for around two days. And so she goes to school and things like that. So the Ed team have just diagnosed her with a mild viral illness and was just about to discharge her. But the student nurse just noticed a few bruises on her inner thighs and her back as well as the flexors of her lower arms. So, before we move on to the next, um, slide, what would we do with this or what would we ask the parents first of all, what information would you want to know? Yeah, exactly how they think that she got the bruises. Anything else? Is there any other information that you'd want to know from your parents? Ok. Let's, yeah, that's very important to rule out any medical course. So, if there's any clotting disorders or blood, um, diseases in the family. Yeah, that's true. Let's go to the next one. Yeah. So I think the first thing is, um, to see whether they've actually noticed it before because, um, they may have not even seen it and yeah, like we mentioned, how did it happen? Um, and if they have noticed it and if they have a mechanism for it, when did it happen? Um, yes. We would also ask about any um any kind of clotting disorders. Um And are there any other Children in the house uh who have also got bruising or just generally? And are there any social services involvement as well? We would ask that for every child. So, yeah. Ok. And so on examination, um we see a very quiet and withdrawn child. Um, she's developmentally normal. She doesn't really want you to examine her. She's like really shy and she's a bit kind of jumpy. Her chest is clear. Her abdomen is soft and nontender. But when you have a look at these bruises, when you undress her, she's got multiple bruises of different sizes and um, they're different ages on the back and the flexors of both arms and the thighs. So what concerns you here? Yeah. But what makes you think about non accidental injury in terms of the examination and the whole story in general? Yeah, that's right. So the bruises are different ages and the child is quite scared. Um, is there anything else that makes you think this could be non accidental injury? Ok. Never mind. We'll get to it. Um So what would we do? Yeah, that's an odd place to have a bruise. That's right. Um So what exactly would we do at this point then if we're thinking about this, how would you go about tackling this? Yeah. Is there anything that we would do before we jump to safeguarding? Yeah. You speak to the parents. That's right because we have to rule out any medical cause for this bruising before we start accusing people of hurting their kids. So is there anything we would do to do that? So we mentioned um about blood disorders in the family? Yeah, that's right. Clotting factor. So we would take a few bloods, right. Let's move to the next slide. Can we go to the next slide? Yeah. Oh, and I think there was a slide before that. No. Ok. Anyway. Um, so yes, abnormal bruising. I think we mentioned this before as well. Um So the green bits, uh she's five years old. Um, kids usually at that age are really, really active and do have quite a few bruises generally. Um, but these are the normal, the green bits are the normal places where you probably would get a bruise where they fall over. So on their shins on, um, the extensor parts of their arms, on their, on their bum. Normally they fall down. Um, abnormal bits would be bits that they probably can't reach to their back, the thighs, um, the flexors, the insides of the limbs and um, the backs of their heads. So at that point, you'll probably be wondering why it's happened like that and what exactly caused these bruises? You would start to question those things a little bit. Ok. Excellent. So, yes, um, first of all, we need to rule out any medical course So we would do an F BCA clotting user, these and maybe a Von Willebrand factor as well just to see what happened. If all of those are normal, we would escalate to the seniors just to say, you know, we're worried about this child because they may potentially um be a victim of non accidental injury. We would definitely get the safeguarding team involved and uh contact the child protection lead in the hospital. And then um eventually we would do a CT head just to make sure that there's nothing going on in there. There's no massive intracranial bleed or anything like that. We would also organize a skeletal survey to see if there's any broken bones and just to have a look at all of the, all of the bones in the body and see because you can see old fractures there as well. Um especially rib fractures. Um We would get the child protection medical examination, which is a very detailed full examination and history taking, which is like it's um very well documented um because that's a legal document that you can take to court. Um So that needs to be done by a senior member of the team and then she also has a sibling as well. So we would bring that child in for a uh child protection medical examination as well. And I actually got this in my exam. Uh sorry, my interview for um specialty training. And um I think the most important thing is to be quite honest with the parents that, you know, this is abnormal for a child this age and we're trying to work out what happened. Um, and so that's why we need to do all of these investigations. And one of the things that could be the cause would be non accidental injury. It's very, it's very important to be quite transparent with the parents as well. Obviously, they can get quite upset. So, um it's best to have somebody else in the room with you. Um just so that you feel a bit safer. Unfortunately, this does happen quite often. Um And you do see this quite frequently. So this is something that you should probably be quite familiar with and it can happen anywhere. It can happen in GP practices in ed and especially in pediatrics as well. Anyway, let's go to a different case now and we'll go sorry. Oh yeah. So how do you deal with a patient who are upset about involving your child protection? Um That's a good question. So normally we, like I said, you have to have somebody else in the room with you and we it it's better to be kind of very matter of fact and nonmotion at this point and just say that just explain the risks and benefits of having this. So the reason why we would do all of this is just to do a full history and examination of the child to make sure that they're safe and also trying to work out the mechanism of why they've got this presentation. Because to be honest, we don't know exactly what happened. Anyway, um we just want to rule out that there is an NN A I um as a medical professional that is your job is trying to keep the child safe in terms of a medical point of view. But obviously you'll have the social services team involvement as well who will then make the decision about what happens to the child and to the family. So I think, I think it's quite important to have your role quite clear. It's just to make sure that the child is safe and not hurt and um how to prevent it from happening again, which you're trying to, you're still trying to work it out, to be honest, unless you've got some very clear results. Um for example, you know, like old fractures or something like that, that's, that's quite evident of non accidental injury. Um but that would come in a bit later once you do the skeletal survey and things like that, does that answer your question? Ok. Cool. Right. The next one is a seven year old girl who came to P AU because of diarrhea and vomiting for the last three days. She's been having fevers which kind of get better with a bit of Calpol. Mum said that she hasn't really been able to keep anything down today at all, apart from a few sips of water. So once again, what would you ask the parents, what kind of information would you want? Yeah. Recent travel. That's a really good one. How, how much has she sh how often has she gone to the toilet yet? If there's any blood? Very good. Yeah. Has she kind of been dizzy or anything like that? Loss of consciousness? Yeah. Abdominal pain. Yeah. Lots of good ideas there. Ok. Let's move on to the next slide. Color of the vomit. Yeah. So yeah, just as usual for anything. How long has it been going on for? I think we already said it was three days just to confirm with the parents how high are the fevers? And what have you been giving? And when was the last dose of paracetamol? What exactly has she managed to keep down over the last 24 hours? I think mum said that she had a few sips of water. But has she tried to give her like any yogurts or anything like that? Um And yeah. How many vomits and diarrhea, diarrhea episodes per day? What is the consistency? Is it like a a bit soft or is it completely watery? And how much is it? Is it a lot? Is she still passing urine? Cause that if she's not passing urine, we might think about dehydration there. Abdominal pain. I think we mentioned that. Is anyone else unwell at home? Has anyone else got this kind of um diarrheal illness and does she eat anything a bit dodgy before? And has anyone else at, at school been unwell? And, yeah, I think the recent travel is quite important as well. So when you have a look at her, uh you want to assess her dehydration? So there's a really cool um dehydration score that you could use um to kind of decide whether or not she's super dehydrated or if she's ok. And so when you look at it, she scores a 34, her eyes are a bit sunken and um she's a little bit lethargic and um the mucous membranes are a bit sticky, but otherwise she is warm and well perfused. Her CRT is less than two seconds. Heart sounds are normal and chest is clear and she's got a little bit of periumbilical tenderness in her tummy and also her blood glucose is 5.1. So we're not concerned about that. So if she, oh sorry if you go back a second, um if you look at her dehydration score, um she scores of three. So if you look at the table, the score of zero is no dehydration, score of 1 to 4 is some dehydration and a score of 5 to 8 is moderate to severe dehydration. So she scores of three, she has a little bit, she does have some dehydration there. So what would we do at this point? You're gonna send her home? You're going to admit her. Are you gonna watch her for a little bit? Yeah, I los is an option. Does anyone have any other ideas? Yeah. Ok. Let's move on to the next slide. So, have you guys heard of a fluid challenge? Yeah. So admit her and observe further signs. Yeah, I guess. But we, uh, she's dehydrated. So we need to do something about that. I think that's right. But we don't necessarily need to jump to IV fluids. Um, what we do quite frequently is do a fluid challenge. So we do 15 mils per kilogram per hour over four hours of diary or really sugary squash. So we can give her some of that and we have to write down, well, we ask the parents to have a syringe and we write down exactly how much they've had. And so we see if they've tolerated that. Um, if they tolerated that, that's great. You can actually just send her home without anything. Um, just a bit of safety netting advice. And, um, it's probably a viral gastroenteritis and it will probably be like this for a few days. But as long as she's able to keep something down, um, that's fine. But if she feels the fluid challenge, uh she vomits that and she's not able to tolerate that. We can give her some Ondansetron anti sickness medication and we can retry the fluid challenge if she's really, really not keeping it down at all, then. Yes, we would have to give IV fluids and IV Ondansetron and we'll probably just take a look at her. Well, we've got a cannulate in any way, may as well take some bloods. So we'll take an F BCA uni and an LFT just to see if she's very dehydrated. And also we would have a look at her urine as well. So, does anybody have any questions about that one? That's a really, really common presentation that you see all the time in pediatrics. Obviously, if her dehydration score is quite severe, we would skip the fluid challenge and go straight to IV fluids and before we can send her home, um, if she passes the fluid challenge, we need to make sure that she is also weeing and that her urine dip is negative as well. Ok, let's go to the next one. So we've got a three year old girl who comes into the GB practice with a two day history of fevers and a cough. She comes in with dad and she, he says that he, she kind of has like, oh, he has a coughing fit, he coughs of coughs and then vomits. So what would we ask dad in the practice? Yeah, vaccination. Super important. Anything else, what would you ask? Yeah. Is he able to eat and drink shortness of breath? Yeah. Yeah. If it's worse at night or in the morning, I guess. So, if anything can make it worse or better? Yeah, I think that's a good point. Ok. Let's go to the next one. So, yes, child vaccinations. Very important. Which vaccinations has he had? Um, are there any siblings? Uh, are they also vaccinated? Uh, so does he go to nursery? Is anyone else unwell at home? Um, is he eating and drinking? And, um, I think he's too big to be wearing nappies and then I think he's like seven. But anyway, is he passing urine and opening bowels that's important to ask as well. So, on examination, um, he's really miserable and he's, he only wants to be with dad. He doesn't wanna leave him at all. He doesn't really let you examine him, but you've managed to do it with some persuasion. Um, he's quite lethargic. His chest is clear and heart sounds are normal. He managed to have a look in his throat while he's screaming at you. Um, and it's quite red. Um, but the ears are fine. Um, and he's warm and well perfused and the observations are all normal except a slightly elevated heart rate and he has a fever of around 38.1. So, what would we do? No, go back any ideas of what we would do. We slightly saw the answers there anyway. Yeah. The swamps. So, if you're quite certain about your diagnosis, then how would we treat whooping cough? Ok. Let's go to the next slide. So, yes, we would take a throat swab. Um, the current treatment for, uh, whooping cough would be Erythromycin for five days. Uh, we would give paracetamol, um, yeah, IDES, we would give paracetamol and Ibuprofen to help with the fever. Um, and the throat pain. Also, we can prescribe some diam, some, uh, throat spray for the child to be able to eat and drink a little bit better. And, um, apart from just being generally quite miserable, all of the observations are fine, they've got a low grade, well, a slightly high temperature of 38.1 we wouldn't really jump to admit them or do anything like that. So we were probably just discharged with safe netting advice once we do get the throat swab though, um, whooping cough is a notifiable disease. So we need to let public health England know about this. Um, there has been a recent surge of whooping cough cases because of the reluctance to vaccinate Children. So it is something that we need to let them know about. So, yes, whooping cough, highly contagious. Um, and it's really uh dangerous for tiny babies under three months and it lasts for a really long time. Um It, it is known as the 100 day cough. And so we all know that it's preventable by vaccines. And so it's caused by a gram negative water tetas um and transmitted by respiratory droplets. So it's more common in infants under three months and unvaccinated Children and they get really unwell because of it. I remember I saw the baby with this and they got really, really unwell um with the clinical features, there are three different phases. So we've got the catarrhal phase, which is just a bit of runny nose, sore throat, conjunctivitis, malaise, and dry cough and a little bit of a fever. So I think that's where we are at the moment with this one. Um And then the pa paroxysmal phase, which is a dry cough and, uh, that characteristic whoop sound. And then you've got the post tussive vomiting, which also this, this child does have, um, and you kind of do get apnea in infants as well. Um, it can be quite severe in younger Children. Um, and it can go on for weeks and weeks. Um, even if you give them antibiotics and then you've got the convalescent phase where it decreases in frequency and severity and it can last for around two months or more than that. So, yes, we would also think about like, um, a viral, uh, t uh, or a pneumonia or a chronic cough or with asthma or uh CO PD or something like that. Um And so yes, we would confirm it with a throat swab. Um, and APCR. So, yes, um, we need to vaccinate the kids at 8, 12 and 16 weeks. So it's part of this vaccination program and then you've got it at three years and four months as well. Um, and you can also do it during pregnancy to protect the infants for um for uh susceptible people. And so the um acute uh management for it is if they're really, really young or if they're immunocompromised, we'll probably just put them into hospital, we would treat with macrolides. So, Erythromycin usually um to reduce the infectivity and then it's just supportive care with rest and hydration and make sure that they're eating and drinking and having enough, um, uh, urine and stool and things like that. And so we might give, um, macrolide antibiotics for close contacts, especially if there's, um, pregnant mums or if they've got little brothers and sisters who are really, really small or preterm, we'll probably do that. And so it's quite important to catch this quite early because some kids can get quite unwell with it. Uh, but if you catch it early then you can prevent it from getting too bad. Ok. Do we have time for one more or is that our time? I think you can continue if you have time. But, um, people can feel free to leave if they need to go. That's fine. Should we, should we just do one more and then we'll call it a day. So we've got, um, a six year old boy who came to P AU because of just one day history of fever, cough and difficulty breathing. And so mum gave some paracetamol yesterday and just put him to bed and then during the night, she went to check on, check in on him and noticed that he was really sucking in his chest and he was struggling quite hard to breathe. And then she got really scared. And so she called 909 and came to the hospital. So, yes, again, what would you want to ask the parents? What kind of inflammation? Yeah. Any rash. Ok. Let's just go to the next slide, asthma or anything like that. So, how long was it? Yes, I think we already said it was one day. How high was the fever? Was he eating and drinking before this? Um is he passing urine and opening bowels? Is he vaccinated? And again, is anyone else unwell at home or in school? It's quite important. And so when you examine him, he's quite lethargic and kind of miserable. His E RT is less than two seconds. Heart sounds are normal and when you listen to his chest, he's got di diffuse bilateral wheeze uh with moderate work of breathing with subcostal and intercostal recessions. And so his observations, he's a little bit tachycardic at 100 and 20. BP is normal temperature is 38.6. Oxygen is 86 in air and respirator rate is 50 which is a bit high for him. So, what would you, oh, what would you do? Um, if you're running out of time, do you think it could be a good idea to um go through the cases yourself or would you still want? That's fine. I can just go through there. So, yeah, his, his saturations are quite low at 86. So we give oxygen, uh we'll give him some paracetamol to uh kind of maintain the temperature to, you know, not febrile. And um at this point, because he's working quite hard and his saturations are quite low. We would probably give back to back nebulizers, which is salbutamol and ipratropium. We could also give him some dexamethasone as well um because it is fairly severe. Um And then after that, we can give two hourly nebulizers and we would review that after every two hours uh to try and stretch him to three hours and then four hours and then um we will try to wean the oxygen down a little bit. Um so that he'll eventually come off oxygen. And then when he does, we can give a wheeze plan to the parents and give them an inhaler and teach them how to use it as well. And on that weeks plan, it should give safety netting advice as well when to come in, when to give some puffs of the inhaler, when they can manage it at home and when they should just call the ambulance and come in right away. So that's what we do for a viral induced wheeze. So yes, it's also very common. Um And it is just as common as bronchiolitis. But for older Children slightly. Um, so we do need to try and distinguish between wheeze and asthma. So we'll probably ask them about, you know, whether this happens more at night time or has it been happening for a really long time? Um, are they able to keep up with their friends in terms of running? Um, do they have eczema or are they allergic to anything, you know, all of those normal, um, normal, uh, symptoms and questions that you would ask them about? And uh we would also ask whether anybody smokes at home. Um That's also it could be a risk factor to um develop a wheeze. And so you might think about an upper respiratory tract infection as well. Um So yeah, the symptoms, you've already got fever, lethargy, not really eating and drinking. Very much increased work of breathing and chest tightness. So, um yes, we've got that. And so to have a look at the severity, we might, it might be mild. So just slight tachypnea, expiratory wheeze and, and minimal work of breathing and they're still able to talk in full sentences and the oxygen is fine. Um We're not really at this stage. So let's go on to the moderate one where they've got tachypnea, inspiratory and expiratory wheeze moderate work of breathing and oxygen saturation. 92 to 95. Still not that bad. So I think we're, we're in the severe point at this, at this at uh for this patient So um marked tachypnea, severe work of breathing inspiratory and expiratory, wheeze and oxygen saturations of below 90 also tachycardic. So, um this kid was uh was quite unwell, but they normally do get better if you treat them quite quickly. And so, yeah, you do need to think about other things as well as anaphylaxis or foreign body aspiration or any kind of uh anatomical abnormalities. And so, um even if you give the uh nebulizers inhalers, if it's just not really working, you might think about a chest X ray and um you would probably do a blood gas anyway. Um Yeah, and then the management. So at this point, we're in the severe part. So we'll get the seniors involved pretty quickly. We would give salbutamol ipratropium with oxygen and uh IV steroids and you, you might consider giving magnesium sulfate and aminophylline if it's, if it's very, very severe. And so yes, the discharge, we already spoke about stretching them as far as you can and weaning down the oxygen and giving a wheeze plan to the parents and making sure that they understand how to use the inhaler and the proper inhaler technique as well. So I think I'll probably skip this one cos I think we've run out of time. Um Let's just move on to the end. Yeah. Thank you so much. Everyone does. Are there any questions? So, with ipratropium? Yeah, I think, I think according to the guidelines, if it is quite severe like this child, we would, we would give ipratropium to begin with. Um If it's a bit more on the milder side where the saturations are still above 90 we might just try the salbutamol any other questions? No, I don't think so. Great. Thank you so much for listening. Thank you so much for that talk and thank you everyone for listening and again, sorry about the slight delay. Um I think you should have got an email with a feedback form, but I've also sent it in the chat. It'll be really useful if you guys could fill that out. Um But after that, yeah, feel free to go. Yes, these los should be sent. Um I will just figure out how to do that that and.