Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, I'm gonna get started. There's not very many of you in the chat, but I don't want to keep you waiting for too long. Um, can you hear me? Yeah. Can someone just pop in the chat if you can hear me and you can see my slides? Great. Thank you. Um, I'm safe. I'm one of the f two doctors currently working at the Royal Free Hospital in pediatrics. We're just going to do sort of a quick speed through the main medical things you see on pediatrics. Um, so obviously Pedes is quite a big specialty. There's quite a lot of different things. It's quite different to adult medicine. So I can't go through everything, but we'll see what we can get through. Um, I would say the most common things that you see with Pedes presentations, our respiratory problems. So unlike adults where you see like circulatory problems, all sorts of things, most Pedes problems are limited to like a or B of your 80 assessment and you see other infections like adults. A lot of cams in my experience is what we see in uh pizza and like really specific genetic conditions which you absolutely need to know about because I don't know what they are until I have to Google them when they arrive on the wood. So I won't be able to go with everything. But we'll see, we'll go through like the main things that you see most often. So, just a quick summary of pizza. So pizza, not small adults. So the same principles don't necessarily apply to adult medicine and pediatric medicine. As I said, most of your presentations are A and B. Um, generally we do far fewer investigations on Children, weigh less blood. So you won't do like flood Brown's every day on Pedes, patient's, um, Mexicans floods won't bleed them. So we have to do it. Uh, it's really hard to blue Children. So we try not to do if we don't have to. Um, something else is we, in terms of obs, we care a lot about a child's heart rate. So we won't send home a tachycardic child. If it hasn't settled. We heard about feeding. Um, a child can't like, understand that if it doesn't drink any water, it's really bad for it. So we have to make sure that Children are feeding well enough. And then in terms of the history, there's a few things in pediatrics which are very specific to Pedes. So especially with young Children, you want to know about the birth history. So the gestation is really important if a child was born really prematurely, um, that can have a big impact on them after like later on in their childhood, especially when they're little. Um, a good question to ask is if they needed admission to a neonatal unit when they were born. Because if you ask a parent was everything okay with the pregnancy and the delivery, they'll tell you that actually they had a really bad morning sickness, but actually you don't care about that. So you need to ask if everything was okay with the baby, if the baby needed admission. Um, and then you can ask about risk factors for fetal sepsis, a nino sepsis. Um, you won't probably need to know this. But you could ask mum in an Oscar, for example, if she knows if she had a group b strap, um, if they don't know what that is, they didn't have it. If they did have it, they will know that they had it. Something else is you need to know about immunizations if they're up to date, especially these days. We're seeing a few like measles and mumps around, um, with parents who don't want to vaccinate their kids. And then another thing, it's important to know if they've, they're attending school if attending nursery, if you've got brothers or sisters who are attending school or nursery, if anyone else at home is unwell. It's the kind of things that you don't care quite so much about in adults. So we'll run through a few cases. So I'm just gonna ask if you can write your answers in the chat. You're more than welcome to also use your microphone. Obviously, I know a lot of people don't really like to do that. So if you want to just have a think about the questions and then write them in the chat, then we can get through the cases. Is that okay? Um So we'll start with the first one. So you're working in a pizza, Any department? And a six month old girl is brought in by her parents. They're really worried about her breathing. They say it looks like she can't breathe properly and don't really know what's wrong with her. So you need to take a proper history from them. So, what are the kind of things that we just talked about that you would want to know from your history? Yeah, for sure. So you're saying onset any flu like symptoms? Yeah. Absolutely. Anything that makes it worse? Yeah. Yeah. Any other noises? Yeah. Really good. Are they drinking, passing urine? Great vaccinations, wet nappies. Yeah. Yeah. These are really important things. You're good. So, a lot of you are picking up on feeding and are they their normal selves? Yeah. There's a really good question to ask if parents are really worried. That's actually quite a useful thing to know. Um, so let's go through the history a little bit more. So, this girl has a three day history of Kreisel symptoms. She's had a bit of a blocked up nose, bit of a fever, bit of a cough, nothing is coming up. Particularly she's feeding okay. Uh, bottle feeds and rather than bottle-feed sand, she's bottle feeds and is having more than half of her normal feeds. So that's a really important thing. We want to know if they're having more or less than half of their normal feeds. Quite difficult to tell if a mom is breastfeeding. But you can say, are they feeding as frequently, as often and for as long as normal. And that can give you a sort of good, um, general view of how, what they're feeding and has had five wet nappies today. So, if I've went up okay, less than four, we might get a bit worried. Uh, no vomiting or diarrhea, no other symptoms, no rashes. Um So in terms of their birth history, normal vaginal delivery at 38 weeks, no complications didn't require admission to the neonatal unit. Immunizations are up to date. Nothing of note in the past medical history. No, nothing of note in the family history. She lives with both parents. The four year old brother attends the nursery and he's got a cold. So next you're going to examine the child. So what kind of things are you, how are you going to examine this child? Yeah. So the answer is always 80. Um So do you know sort of some of the things that you're looking for in terms of assessment of a child's breathing. Yeah, respiratory distress. Does anyone know what the signs of respiratory distress are? Yeah, nasal flaring, grunting, tachypnea, recessions. Did they rose? Abulia head bobbing is very young if the blue. Yeah, these are all really good answers. Trickle tug. Perfect. So things like uh nasal flaring and head bobbing, you see a bit more in like babies but like your little like a couple months old, a couple weeks old. So you look at this child so a airways patent know, stride or no airway sounds, but you see some moderate work of breathing. So there's a bit of subcostal recessions. A bit of trickle tug. There's no head bobbing. No nasal flaring was good air entry. But you can hear some craps on both sides. A little bit of a wheeze, that's, that's about 90% and their respirators 52 which we're going to say is high because obviously the ranges are different, depending on the age. I didn't think you would need to memorize the obs ranges for Children because they're very, quite a lot. Um, c is more or less normal. Do their alert. They're fine, e abdomen, soft, nontender. No rashes. They've got a mild fever. So, what do you think is wrong with this child? I'll give you a, it's like this is January. Yeah. So bronch, so bronchiolitis is, by far the most common thing I've seen on ps I've done peas over the winter and it's like the vast majority of what we see in any is bronchiolitis and RSV is the most common cause of bronchiolitis. Uh One clue here is that this is day four. It's got three day history. So this is day three or four and that is typically when bronch gets worse. So that's the classic picture, especially with RSV, bronchiolitis that they will be okay and then they'll get worse at day four and then they'll improve. So that's worth bearing in mind if you see someone who's day one day two bronch that they might actually get worse before they get better. So it's something to mention to parents. So, um were you going to do now, immediately after you've just examined this child? So just as a reminder, this was the examination. Is there any immediate interventions you want to do? Yeah. So perfect. Give some oxygen. So 90% that's not enough. Um So we need to give a bit of oxygen. Probably don't need to go in like with a non rebreather face mask, you could probably start with nasal cannula three liters and see how that works because actually that's in over 90 we're kind of happy with, with Pete's. We don't need to be quite resilient. You don't need them to be 98 if they're over 90 were generally fairly happy aim for like 94. Um Importantly, don't give any salbutamol in bronchiolitis. Um, that there is, you can hear a bit of a wheeze sometimes but the weeds isn't actually because of a reversible airway obstruction. So, the salbutamol isn't going to help Children who are this young. It doesn't really work and it's just going to make them tachycardic. If you give it, it's fine, you're not going to cause any harm. It just might make them a bit dark aquatic, but it's not particularly going to help in a child of this age. Um, are there any investigations that you want to do? It might not be? Well, I'm not sure what you mean by U E sorry, but yeah, you want to keep an eye on their sats. Um, they're probably going to come in so you can do a little nasal swab. Um, you can do a chest X ray probably would discuss that with the pediatrician just because we care a little bit more about a radiating child uh radiating a child. Yes. Alright using these. Um but if a child's requiring oxygen, you might want to do a chest X ray, especially if you've had some craps, terms of bloods probably wouldn't. Um It feels very strange on pediatrics. You really barely ever bleed a child unless you absolutely have to. It's really hard to do the samples often you don't get enough unless you desperately need it. We don't tend to do it. So in this case, uh they're feeding okay. So we're not particularly worried about their hydration status. We know what's wrong. With them essentially. Probably wouldn't bother. Um, you probably wouldn't be wrong in and ask you for suggesting it. But in real life I probably wouldn't. Okay. Great. So, yeah, that's bronch. That is far and away. The most common thing you'll see in Children, uh, under the age of like, two in the winter. If the viral swab came back positive for RSV. Yeah. So, at the royal three you swab, everyone who comes in and if anything comes back positive, they get put into a side room are rapid swabs. Only test for flu COVID and RSV. But they would need to be put into a side room. If there were side rooms free and they tested negative for all of those. You probably would still put them uh in the same, you probably would put them in the same. Also an aside you is an end. Yeah, an NP aspirin is the same as well. I don't know why they call it that. Just a nasal swab. Yeah, it is an N P A is what you can order from the computer system. Um If you have any more questions, please put them in the chart. If not, we'll carry on to a second case. There's a bit of a theme. His three year old boy was brought in by his mom who is very worried, he's been wheezing since this morning and she feels like he's getting a bit tired. He would, he'd been sort of happily walking around playing well, wheezing, but he's just looking a bit more unwell now. So, again, what do you want to know in the history? Yeah. How many history of H P eczema has it happened before? Yeah. Okay. And then all your sort of normal Pete's questions, or there are three year old, we probably care a bit less about the birth history. Has he eaten anything? Yeah, that's actually a really good point. I didn't think of you want to make sure that he's not having like anaphylaxis or something because you do see that in Children. I've seen it twice in four months. They've been ill recently. Any fevers yet. All really good questions. Um, okay. So, let's see. So they've had a one day history of Coryza symptoms that we started a bit later after the cold symptoms. They've had mild fevers, a little bit of a cough. Nothing much coming up. Feeding fine as well. Hasn't probably not enough but has been passing urine. Well, um, mom actually has a self useful inhaler at home and has given him two lots of four paths. It hasn't really worked. Um, I was born like elective Cesarean section at 39 weeks. No complications. Everything was fine. Immunizations are up to date. But when you ask about the past medical history, actually, he's had two different attendances to hospital with respiratory symptoms that mom says are a bit like this one time he did require admission and he actually has, has a salbutamol inhaler at home, which doesn't normally have to use, but occasionally does in the winter he's got X mown hay fever mom has asthma. So you also trust that she's giving the subject of an inhaler properly because that's a really important thing. Um, and she's given it with a face mask and, uh, I think, um, and he lives with both parents and three siblings, one of whom also has a cold and he attends nursery. So, uh next you're gonna examine him. What do you think you're gonna find on the examination? Ok. Upset already. Yeah, you want to make sure that his starts are okay. And uh mom says he's been wheezing and she can hear his wheezing. So you're probably gonna look, find a bit of wheeze. So always A T E always the go to assessment Airways Patent. There's no Stridor all b there's a bit of mild work of breathing. He's got a little bit of risk, subcostal recessions, but you can hear actually really good air entry. Um And you can hear an expiry, Torrey weaves throughout Cers and this, that's 95%. So that's fine and then the rest of the examination is normal. Um Why do you, why is it really important to check if there's good air entry? Yeah, so, um, Wheezers tire, it's really hard to breathe that hard if there's like your airways a bit obstructed. Um And if it gets really bad. Sometimes they're not able to breathe in as effectively and the air doesn't get to all of their chest. And like adults, this is a really bad sign. Also, occasionally they got fragile lungs, they could get new moth or it ease. Um, and you just want to check that everything that you can really hear the air entry everywhere. So it's really important to spend a good time listening to all of the chest like the, the base is the apex, everything. Oh, no, I forgot that my thing was there. What is this? It just showed you. But what do you think this child has got? Yeah, well done. Sorry, I thought I wrote. What is this? But I didn't. Um, so this boy has a viral waste. You cannot say that a five or three year old has asthma. They can't do lung function tests. They're too young. We just can't diagnose anyone at the age of five with asthma. So up until that point, it is viral induced. We's um, you can tell parents that if they're having viral induced weeds as a baby, as a young child, they're much more likely to have asthma. He's got a history of H P A family history of asthma. He's quite likely to go on to develop asthma, especially as he's had multiple episodes of the viral induced weeds now. Um, but it's just really important if the child's under five, never say that they're having an asthma exacerbation. They're having an episode of viral induced ways. So, what are you going to do? Now? You've got a boy in front of you who's quite wheezy. Uh, he's got a bit of work of breathing. So, what's your next step? Yeah, it's Albuterol. Does anyone know how we give Salbutamol? Two Children with violin juice? Tweeze. You might not. That's fine oxygen. Probably not. So, there's, that's a 95. that's fine. Yeah. Best therapy. Does anyone know what that is? I didn't until really recently. Yeah, that's fine. So best therapy is to lots of 10 puffs of subsides. Mom about 10 minutes apart along with plus or minus two puffs of ipratropium. Depending on how easy you think that the child is, um, back to Mykonos. Yeah, it's sort of, so, it's just, it's too, lots of TEM puffs in a child this age, you're going to give them via a face mask in a chamber. Um, and you just need to hold it for quite a while or you can give an up, but probably in this case you wouldn't because he don't need any oxygen to stick to inhalers. Perfect. Um, what do you do if that works? What are you going to do next? And that's fine. This might be a bit pass. Yeah. At least four hours. Perfect. So you're gonna try and give them regular salbutamol just two puffs or four puffs. Um, you'll say that they can have it hourly. So you'll probably prescribe this albuterol for the next hour, but just review them just before the hour and see if they actually need it yet. If, and that depends on the sats, if the wheeze is improving and how their work of breathing is and then you'll review every hour until they can have it at two hours, which might be immediately and then you'll again, review every two hours until they can have it three hours or four hours. And we call this stretching. So you try and stretch them to four hours and once they're only needing salbutamol every four hours, you can send them home with a Wheeze plan where they'll have four Allie salbutamol for about a day and then they'll gradually wean that off until he doesn't use anymore. If it hasn't worked. If the best therapy hasn't worked, then what are we going to do? This is a very good point. So you wanna make sure that you haven't actually misdiagnosed it? No, that's true. Keep them in hospital. Absolutely steroids. Yeah. So you need to think about that. You can, in the first instances, you can repeat the best. But at that point, if it's still not working, you're thinking you might need to give them some steroids. So probably just a bit of oral decks. Consider N I V it's probably a bit. Um He's in himself this example. He's quite well. We call them like happy Wheezers. Um but it is down the line. That's where you need to start thinking, it's like an asthma exacerbation in that there's many steps but like, ultimately, if nothing's working, then you need to think about more invasive methods. Um We don't really give kids N I V because they won't tolerate it. We give babies an IV sometimes, but a child's not going to keep a mask on his face, to be honest with you. So if it was getting that serious, we'd probably interpret them. Um Great. So yeah, that's viral induced sweets. Again. That's like the second most common thing that we do. I spend quite a lot of my time on my night shifts going to review a child every hour to see if I can increase the like stretch their salbutamol quite a labor intensive thing to have on the ward. Um But it's quite straightforward, the vast majority will just um we'll just recover after a couple of days of steroids. What do parents take home after they're discharged? Salbutamol? Definitely this child, I would probably want to send home with an inhaled cortical steroid just because it happened a few times. Now, I'd probably discuss it with the pediatrician, maybe even one of the pediatricians who's more specialized in asthma and allergy. Um but, or even though they haven't got an asthma diagnosis, the fact that it's happened quite a few times you would want to consider a steroid, but not always. So that would definitely be something to have a further discussion with a senior about. Um But from my experience in a case like this, you would, they would go home with aquatica steroids as well. Sorry. Being around Children, you get all the verses. Um If anyone has any more questions about viral and you squeeze pop them in the chat and then in the meantime, we'll just move on to the next case because I'm being a bit slow. Sorry. Um So the next is a two year old boy, he's brought in by ambulance. Dad's really worried. He's making like a really strange noise when he breathes. He woken up this morning with a barking cough and a slight fever. And then throughout the day, he just got worse and he started making this noise like so obviously you go into the room, you hear this noise, you hair Stridor. Uh How will you examine the child and then Charlotte, why do we give that? How do we give the extras orally? They can have its liquid? Don't agitate them. Yes. So broadly speaking, don't examine a child with strider is what I would say. Uh Don't dare that you don't want to upset a child who's stride during, you can stay far away, wave at them if they seem really happy and you feel confident that you can have a little listen to their chest and get some sats without upsetting them too much. Then by all means go for it. If you've got an extremely strict Bulus child just don't, don't do it, don't go near them. The priority is making sure that the airway remains safe. Um, it is A T E and you just stay at a, because you've got a stride door essentially. So, yeah, I just don't really examine them is the main thing to know if you've got a child with dry door. Don't go near them. What are you going to do instead? Yeah. Cooler senior. That's really important. Um, a lot of Children with croup, uh fine, not that sick. But if you're hearing the Stridor just as you enter the room, then this is quite severe. So you want to make sure that you've got someone there who can manage the airway. So I personally would not feel very confident. So I would want to call my consultant probably as I don't have a wretch, but you could read and I would want to consider calling an anesthetist. Um, is there something, is there an intervention that you can do? Which will be helpful? We're going to assume that this child has been drinking water positioning. Yeah. So make sure that they're set up, right? You can give them oral decks. If they're drinking, it tastes quite nice. Don't like it. So you can give them uh oral decks through a syringe. If they're tolerating orals. If they're not tolerating orals, they're going to need a cannula and they're gonna need IV steroids. You should absolutely not try to do this. You need an anesthetist there when you try and cannulate a child, Children get so upset when you cannulate them, they don't understand what's going on. Usually need like a couple of people to hold them down. It's all quite traumatic. So this child is gonna scream and I would not want to be the only person that if this child starts screaming because if they compromise that airway, you need someone there who can manage it really quickly. So never attempt to cannulate a child with group without an anesthetist. Um So actually you probably as a junior as you wouldn't do very much, you could give oral steroids and make sure that you've got senior support. And that's what I just want to highlight is that if there's an airway obstruction, you need to make sure you've got a senior, they'll know what the top differential uh for this, you can give nebulized adrenaline. We don't tend to, um, you'd mostly only it's in the guidelines if you can't really get steroids in as like an intermediary. But the priority is to get steroids, it's possible you can do it, but it's not the first line. So, yeah, epiglottitis and back to your track yards to the two most important differentials group is 1000 times more common than any of these. So it is almost certainly always going to be group. But you need to have that in the back of your mind. There's a few things that are different between croup and epiglottitis, which you'll mostly get in the history. So they'll probably not have had any Kerasal symptoms. They probably won't have had, they'll probably, it won't have like, gradually come on. Like this child, they'll probably have got really a more, really fast, they'll be drooling. It's much more cute and it is just much less common. Common things are common if it's this like spring croup is really common um around like February March. So, you know, it is much more likely to be that, but it's really important to have this differential in the back of your mind. You're not going to do too much harm by doing the same things. Again, you want a senior, they're E N T if you've got it an anesthetist and you don't want to agitate the child. And does anyone have any questions about group, um, pop them in that shot and then we'll move on to a slightly different one. So there's like your, there's three main respiratory things and they are the three main things impedes that you'll come across bronch group. And by energy squeeze, I found it really difficult when I was a student to work out, which was which so group is upper airway. So it's strider. Viral induced squeeze is lower outweighs. So you've got more, we's like a bit lower down, but it's still your airways and, whereas bronculitis is more like interstitial, so you get, um, craps rather than weeks. Although sometimes a bit of with, that's not the main feature. So we went to another case. So you've got a five, this is very closely based on the thing that happened to me on Friday night. Um, you've got a five week old girl who's brought into E D by her parents. She's not, she's not been feeding very well for a couple of days. She's really irritable and she's got a temperature of 39.2, which was taken at home with an axillary thermometer because as a side note, the forehead, infrared one's completely useless. You need an axillary one for a baby or, uh, and air one. Are you worried? Yeah, it would always worry about fever in less than three months old. Exactly. Right. In a baby who's less than three. Any fever is meningitis until proven otherwise. Um, so you need to, you need to treat them as if it is meningitis. Uh Sorry. Um, what would you, so you assuming you've taken a history? There's nothing much else of note. They've just been crying loads, feeding much less. Well, barely anything at all. Reduced, wet, wet nappies. Um, and they've had a fever for about a day as high as 39.2. What do you need to do in this case? So, well, so imagining. No. Sorry. What would you need to do in this case 80 and a sepsis screen. Yeah, absolutely. Culture everything. Yeah, absolutely. Everything. That's right. Full septic screen. Yeah, perfect. So what you want to do the opposite you want? Obs as I mentioned for Children were much worried about heart rate than anything else because that's the first thing that you'll notice we don't really take a BP very often at all. Respirator you care about, but Macy in terms of respiratory effort, um you want to do a really thorough examination, obviously, as always an 80 you want to culture everything. That's absolutely right. And you would in this instants, take bloods, um you would do a full blood count using the CRP blood cultures, you could add lefties and clotting if you wanted. But as I mentioned, it's actually really difficult to get blood off Children. So I'd prioritize the first ones and the blood cultures. You want to do a chest X ray to make sure it's not chest source and then you will need to do an LP. So believe it or not LPS are actually easier on babies because they can't really move, you can hold them really like a banana and they won't move at all. And it's much easier than an adult, but you would not have to do this, the consultant or the reg would do it. Um So, so you've done all of these, this is what you find, you find that the baby's really tachycardic, they're quite febrile, you feel the anterior fontanel. So, you know, here you feel it by just sort of rubbing your finger across off the head and it feels really sunken. They're central cap refill is three seconds. They've got very cool peripheries, very sunken eyes. The urine dip and culture are normal, the chest x reality in a second. Um You take some bloods, obviously, the blood cultures aren't back, but the CRP is 60 the white cells of 25 then croutons raised and then you're gonna do an LP and send that off. So what does this, what worries you about these findings? Babies dehydrated. Yeah, give some fluid, they might be dehydrated. Absolutely, slightly raised. Cracking in, in a baby is really hard to do. You have to be like pretty dehydrated for it to show. Um You would probably also do a gas. So if we're gonna assume that this is the baby that I saw Friday night, his was actually 180 which sells the 30. You're going to say that the gas, the ph is 7.1, the base excess is minus 19. Uh So we've got a metabolic acidosis. This is really worrying, very worried about this child. So it gives some fluids. That's a really good thought. So first, let me just show you the chest X ray. What do you think about this test X ray? This is a five week old baby. Do you think it looks normal this is a hard question. So the left, this is why I wanted to show you this. You said there's an opacity in the left upper zone, abnormal heart enlarged heart. That is the thymus. The thymus does not fail to confuse me every single time. I look at any needs a chest X ray. What you're seeing at the top, I can't actually point at anything with this unfortunately, but on the left side you see there's a bit that sticks out over the left heart, over the left side of the heart that is the thymus. Adults don't have one. So we don't see this. You only see it in like really young babies, but it is extremely confusing every single time. So that's actually not a problem with the heart is the thymus. So this is broadly a normal, a normal looking chest X ray. There's a bit of like patchy changes, but it's quite hard to find a normal. Then it's a chest X, right. Um So you just bear that in mind that, that what you're seeing there is the thymus. I don't know if you would be asked this in and ask you that seems like it would be really mean. But yeah, I get confused by this every time I look at an X ray. So sorry. Yes. So you've done your, you've taken your blood coaches, you've taken bloods, you've done an LP. This is all part of what keeps process that we also use in adults. You are unwell. That was poorly phrased. So it's all sort of part of the sepsis. Six. Yeah, perfect. So, what have we not done yet? So we've taken bloods and we've taken blood cultures and we know the lack tape we're gonna say is five because that's what it was on the baby on Friday. What else do you want to do? Urine output, wet, nappies, antibiotics, oxygen. So with oxygen only if needed. So actually, this baby probably doesn't at the moment that they've not really had any respiratory symptoms, but that is part of it. So we give antibiotics, fluids, oxygen except oxygen with a pinch of salt. Um So we absolutely need to give antibiotics and we would need to give fluids and we do need to check for the urine output. So, on this baby that we had on Friday, uh the baby had to come in with three ish days of profuse diarrhea opening. It smells 10, 20 times a day. Not really feeding mom was really, really worried, took him to an an E that I will not name three times and was sent away with reassurance and then finally presented to the royal free. Um And this baby looked like it was about to die. It was gray. It's eyes were sunken. I'd never felt a sunken fontanel before. I always thought maybe I was not going to be able to tell. You can absolutely tell. It's like a huge krater in the top of their head. Um looked cachectic wasted. It looked a bit like it. And if everyone seen the last Harry Potter film looks a little bit like the thing that Voldemort is in his head in the baby. The baby is now fine. I will see. So we gave fluid so we gave to fluid bolus is fluid. Bolus in a baby is 10 mils per kilo. You would not be expected to know that. Um mhm So you need to treat as if, as I mentioned as if it's meningitis, the royal free guidelines for meningitis triple therapy. IVF taxi him for a baby that has really good gram positive and gram negative cover. You give it four times a day. IV um IV amoxicillin. This covers specifically for listeria meningitis. Uh even if you don't think that's what it is. That is the treatment until your cultures back. And IV sorry, not I see a sick liver to cover for HSV meningitis and then you need to make sure that you're giving them paracetamol for comfort. Um and for the fevers and then fluids or N G feeds depending on how unwell they are. Um we mg feed young Children quite a lot. So if they're not particularly unwell, you could put in an energy and give them die or a light or milk through the N G tube in a child. This unwell, you absolutely wouldn't want to do that you'd want to give their, got a bit of a rest. So you'd put in a cannula and give IV fluids. Um, there's very specific maintenance, fluid calculations for a baby, which I don't think you would need to know. Um, for a neonate, it's 100 and 50 mils per kilo per day, which is what we gave this baby who was 27 days old. If they're a bit older, it's like 100 mils per kilo for the 1st 10 kg, 50 mils per kilo for the next 10 kg and then 20 mils per kilo for everything after that. But you want to make sure that they're fully hydrated. Um And then over time you can try and introduce feeds again. If they're there somewhere, you probably want to give their, got a rest for a while. Does anyone have any questions about that? This is just sort of to cover a septic baby? It doesn't happen very often, but when it does, it's really scary. Um And again, you wouldn't handle this on your own. You'd absolutely call a senior, but just to point out that babies can give, can become really septic and it's actually really horrible to see. So this baby on Friday is not fine. Um, the fluids and antibiotics was, would you give both antibiotics and acyclovir if results haven't come back yet? So you would start with triple therapy and you will not stop the Acyclovir until your CSF PCR is back, which is unfortunate cause it's not particularly nice to give us Acyclovir. Uh IV, it's not particularly good for you but you can't really stop it. You won't have a leg to stand on if you stopped someone's Acyclovir before the cultures back. Um And then once everything's back, then you can think about stepping down. Um often you'll find that there was never anything particularly and it was actually a virus the whole time. In which case you can stop everything. Um, I suspect that's what will happen with that baby on Friday. Last time I checked there wasn't, nothing was going on anything. Oh, no, sorry. Too far. Um, we're gonna do something slightly different now. So a six month old boys brought in by his mom, he's crying constantly and you want to take a thorough history. I'll just waster it because, um, we're a bit short on time. Mom doesn't know what happened. The baby's been crying for five hours. She cannot tell you what's wrong with them. There is no other symptoms. There's no fevers, they've not appeared unwell. They're normally, well, completely normal background. No concerns. Um, the baby lives with mom and her partner. The family are known to social services. Mom is under the unity team, which is the, our local team for like drug and alcohol services. Um, and you examine the child. How are you gonna do that? It's not a trick question. So it is just 80 again. Yeah, there might be a bit of a delay with your messages. I'm sorry if I'm going too fast. Yeah, a 80 top to toe. Absolutely. Right. So you do an aide to the assessment. Always patent breathing is normal. Sears, normal D they're just really upset, crying all the time. Um, e abdomen, soft snow fevers, you undress him and you noticed that his left thigh is really red and swollen. Um, what are you worried about DVT cellulitis is a really good um, other thing to think about that's actually not, I was getting out here but I didn't really think that so. Yeah, but I guess you would be able to tell if you actually saw the child but N A I absolutely, that's what I'm alluding to here. So what are you going to do? Yeah, history of mechanism of injury if one is suspected. So if you think you found an injury, you need to get a really clear history from the parents. Um, because sometimes things can happen and you know, accidents happen, but you need to make sure that what they're telling you much is with what you're seeing, tell the parents you suspect and used to scan senior help seniors safeguarding. Yeah, all of this is absolutely right. Um, you need to be transparent so you need to tell the parents I need to cool a senior. You're gonna need to contact the social workers and you're going to need to do some investigations. Um, you do an X ray and this is what you see, pediatric X rays are a little bit harder to interpret because of growth plates and so on. But can you see what the obvious abnormality here is? Yeah. So you've got a massively displaced femoral fracture. Like, I don't know if you can like that part and that part should be like this. Uh, so yeah, there is really no short of like a car accident. There isn't really any way that a child could do this by accident without something happening to them. The six month old isn't like writing about, you know, this is quite a high impact injury and immediately raises safeguarding concerns. So as you rightly mentioned, you to inform your senior, there's usually a safeguarding leaves in every hospital, you probably inform them as well. You inform the mom that you're gonna need to contact social services. Um and why and then you need to make sure that you finish like a really thorough examination. I have a child that's quite a stressful thing to do. Um I've had to do a few times where you have to undress the child fully. So probably do it in stages like to not upset them and just look at all of their skin everywhere just to make sure you're not missing any injuries, look in their ears, look behind their ears. Um You need to examine everything including the genitals direct. Um absolutely everything and you need to document extremely carefully what you see. So if they've got a little graze on their knee, you have to write that. If there's like an old looking wound, you have to write that you need to write absolutely every single thing that you see and you have to be really objective. So you don't want to say like, oh mom was behaving a bit strange, like, don't put your own opinions into it, just literally write down what you see what's happened. What's the place of clinical images? Yeah. So uh I've never actually personally called them to look at a safeguarding case, but probably quite a good idea. Um In theory, I've done a project on N A I and it wasn't something that they used. We just had like really careful documentation from um everyone other. This was M Barton. Um really careful documentation from the clinical team who've seen them getting clinical images. Probably not terrible idea. It's quite hard to do in practice to get hold of the person who does the clinical images have to say. Um But it's worth considering, especially if you've got like quite a lot of skin changes and you think this much something that's gonna need to go to court or something, but that wouldn't be up to you to decide that would be for someone more senior. Um If in this one, you probably weren't a skeletal survey. So a skeletal survey is a series of x rays of basically the whole body to look for any missed injuries, any old fractures, anything like that. So it includes like uh skull, chest, everything. Uh This total need to be admitted for a place of safety other than ps what other teams are involved. Um Social services. So at the royal free, we've got really good safeguarding team and they get involved. Um Again, once you've alerted your seniors in the safeguarding team, your duty is just like ensure that they're medically well and that you've not missed any other injuries, but usually social services, the police might need to be called often. Yeah, the police have to be involved after we unfortunately don't see this too often. And when we do CNA I it's not usually like it's like bruises and things. It's not 10 doesn't tend to be this bad, but it's really upsetting um dizzy and it does happen depending on where you work, you'll see it more or less often. For example, I know at North Middlesex Hospital it's a really big part of Pedes, the Royal for it's less big of a part, but you do still see it. Um I've got another case but if I could ask you possibly to fill out the feedback form while we go over the last case, that would be amazing, we'll wrap it up quite quickly. Um So if you are able to just quickly scan this QR code, I would be very grateful. Just give you a second. Okay. So this is the last case. This is actually what I had as my final Czarsky uh for Pete's and you had one stations I did peet's during peak COVID. So basically didn't do any pizza, you know, but this was my station. You're working in a GP practice. A six year old girl is brought in by her dad because she's had fevers and a rash for a couple of days and she appears to be really itchy. She's got no other symptoms. She's normally, well, there's nothing much of note in the rest of the history. Yeah, you'll also get the link for the food back after. Um Thank you. Um So you examine her. She's got a bit of a 38 5. Nothing too dramatic and then erythematous rash covering her whole body. There are some vesicles with fluid, some are scabbed over there. A theme of blanching and you can see some excoriations of the skin and the rest of the examination is normal. What do you think it might be if you just pop your answer quick, multiple choice questions. Finish up. Sorry, I just need to let someone's trying to deliver something to my house. I'll be one minute. I'm really sorry. Sorry. Can we do it? Details one more time. She's got a fever, a widespread rush over her whole body. Some vesicles with fluid, some scabbed. Evolution's the their blanching, some excoriations. The rest of the examination is normal. There's one for chicken pox. So yeah, chicken pox, common things are common. A lot of chicken pox. Um I'll just talk through why the others are not, right. Um Mess a meningitis at any rash. You need to just make sure that it is not a non blanching rush, patiki eye. A non blanching rash does not exclusively mean meningitis. In fact, you only get that in meningococcal sepsis. It's quite specific kind of meningitis. Um But if anyone's got nonblanching uh petechia, you need to assume that it's meningitis until you can prove that it's not um it's not eczema herpetic. Um Is that just something we see quite a lot in Children and it's worth being aware of. They'd have a history of um eczema and probably be really young, like very small or one of the parents has a cold sore and then they get quite unwell from it and they like kind of yeah, like um really angry red spots in the eczema monkeypox. I run out of things that have spots, but that's sort of it doesn't fit the description. This isn't the right demographic for monkey box. Um measles. This is not quite how measles looks and then usually unwell in other ways. Um but it's worth keeping in mind and maybe just having a little read about because I've seen in the last four months, I've seen two cases of measles um and sometimes Children get really, really unwell from measles and just with the general population being less, less population getting vaccinated. And obviously, like, even I saw a child who had been vaccinated with measles because they're not 100% effective. So if there's not herd immunity, you can still see other Children with measles. But again, this doesn't quite fit the description and chicken pox is the most common. I think it's very, very common use it all the time, especially if you're working in GP. Um, but the main thing to know is what kind of advice do you need to give to someone whose child has, uh, chicken pox, stay at home until all the lesions have camped, avoid pregnant and immune compromise its own school careful around pregnant women. Yeah. So that's, yeah, that's the key thing you need all of the lesion's to be scabbed over before that they can go back to school. Um, paracetamol for fever. Absolutely. So you could just ask how the rest of the family had it or being vaccinated. It's not going to make much difference to what you do, but just to warn them that if they've got another child who's not had chickenpox, they probably will get chicken pox. Don't attend school until all the physicals of scabbed over as you've said, um, inform the school. So they might want to just let the school knows that they can notify other parents that there's someone with chicken pox. Um stay away from any pregnant women or immunocompromised patient's really, really important. Um pretty smart and not ibuprofen. So there's like a theoretical risk of association between ibuprofen and chicken pox and necrotizing fasciitis probably not going to happen. But it's um you can't really justify not saying that just to someone um exceptionally right. I have seen one case of necrotizing fasciitis. It was not due to chicken pox number proof and it was due to invasive group a strap. Um If they're really itchy, you can give peritoneal chlorphenamine probably before they go to bed just quite settles the itch a little bit and makes them a bit sleepy. So if they're not sleeping at night because they're really itchy, you can do that. Um, you need to try and stop the Children from scratching, which is really difficult to do if they're scratching at night while they're asleep. Some parents put mittens on their Children. Um, it stops them from scratching because then they can get infected and then if anything obviously need to safety net as with everything, if they look like they get infected or they're getting new ones, then they need to come back. Okay. Um, just because obviously it pedes is a huge topic and we can only go over a few things in an hour even they've run over three. Um, but just things that are worth looking up in your own time are developmental milestones and vaccination schedules. I have no tips as to how to memorize this better than just trying to learn it. Unfortunately, I mean, just check with your curriculum whether you need to memorize them in practice, you just look up, you don't need to know this little by hot, but it's good to have some awareness of developmental milestones. This is easier to do if you know Children, if you're around small Children, it's really hard to conceptualize if you don't see Children on a day to day basis. Now, after four months of ps, I'm only just sort of getting to grips with what a normal like six month old should be doing. Um We haven't covered limping presentations. I don't know whether this was covered in your surgical pedes teaching if anybody went to that because most of the things are surgical. But the most common cause of a like limping child without an injury are great is transient synovitis. So just looking perfect. Um I don't know how much you need to know about neonate. It's probably not very much. Um but something worth knowing about is neonatal jaundice very briefly. If it's in the 1st 24 hours, you're worried and you have to assume that it's a septic baby until proven otherwise, after 24 hours, less worrying, obviously, then you need to check the bilirubin levels. They might need phototherapy. If it's really high, they might need an exchange transfusion. I've never seen that happen. Um If they have prolonged jaundice, then you need to think about other causes. So this is after two weeks. So um it's usually because they're breastfeeding really common, but you need to make sure that you don't miss biliary Atresia, which is the most worrying cause of jaundice in any, in a, this is when you don't have a bio duct or you have a really, really thin bile duct. So there's no bile going out into the Judy numb. Um This is exceptionally rare. However, we have a child under us at the royal three who had this. Um And it was missed. Um It was only picked up when he went for his immunizations and he didn't stop bleeding all night. So they did some tests and realized actually his liver function tests were horrible. His clotting was really deranged. Um And then he was found to have biliary atresia. Um Something that you can do to test for that is you do a split bilirubin. So you look at conjugated and unconjugated bilirubin Children with biliary. Atresia will have a really, really high conjugated bilirubin because the bilirubin is not going out of the bile duct. So it's going into the blood and it becomes conjugated. It doesn't give you connect a wrist because it's mostly conjugated. But um oh if it's, if it's missed, you go into liver failure. So this child has uh there's a procedure that they do where they try and like create passages, it's a bit beyond me. But it's called a Kasai procedure in this chart. It didn't work. So now he's in um liver failure, acute liver failure, and there's needing a liver transplant. So it's just really important to be aware that even though it's exceptionally rare, that's the thing that you'll miss you're looking out for. And then you might be asked a few things about really common. Uh Where was the child bleeding from? From the injection sites from where the vaccines were put in? His legs didn't stop bleeding. So they did some clotting and liver function. It's really sad. He's really lovely boy. Um And then yeah, some comments syndrome sue again, like the things that we actually see in pizza, like really weird syndromes, like maple syrup, urine disease and like very specific syndromes that cause seizures. But you don't need to know that you will just look it up if someone comes in. But things like trees and me 21 might be worth knowing sort of generally what the heart defects are and things like that because that could come up. Um That's what I've got for you. Sorry, I've overrun a little bit. It's quite hard to cover all of Pedes medicine in an hour. Um So if you have any questions, I'll hang around for a bit. You can ask them in the chat, you can put your microphones on if you want or you can email me. Um So if you dot Hardy ate any chest on it if you've got any questions. Um So thank you very much. Sorry, I've kept you 12 minutes over the time. But yes, any questions let me know and then I'll put the feedback here. I could um could I clarify about tachycardia being bad in Children? Yeah. So Children can look really well for a really long time and actually be quite as well. So they can appear to be completely fine and then they'll just all of a sudden or fall off a cliff. And often the only sign that that's going to happen is um that they're persistently tachycardic. So that could be because they've got fevers, having a fever, we called tachycardia being in pain will cause tachycardia. So it's not in itself worrying, but you just want to make sure that the tachycardia will settle because you don't want to miss like a septic child who looks fine because you always hear stories of a child who's looked really, really, really well, it's just been a bit tachycardic the whole time and then has just crashed. Um So we will never send home a child who's tachycardia is not settling. Hopefully, that answers your question. I'll just be here for like two more minutes in case anyone has any questions. But thank you very much and thank you for participating and giving up your evening stop. It