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Uh yeah sorry guys about the technical stuff. I'm not really sure what happened there, but we'll get cracking now. Um It shouldn't last any longer than than seven o'clock, so don't worry if you've got plans and stuff after seven um So like Yasmin said my name is Gurpreet, I'm currently an f one. I've finished my rotation Gastro and I'm working in Children orthopedics now um and I've been part of the hospital in Cardiff where I graduated from since I think first year and then went on to do national from the year before last, um So we'll get cracking into it um So I'm talking about pediatric course spiritual disease today, which is one off the more common presentations that you might see for any child, presenting in e. D. Or in a. G. P. Surgery, so it's one of the bigger topics of pediatrics. Um I've tried to cover as many of the conditions as I can um. And I've tried to kind of put them, put the main point on to one slide for each disease, so the slides might look a little bit overwhelming but I'm hoping when you go back over them. If, if you need to then um it'll act like a kind of q card for each disease, just so it makes provision a little bit easier um like Jasmine said, if you've got any questions at all or whatever, then please feel free to drop them in the chat, and I will answer them as we go along, so just going through the learning outcomes. Um we'll go through signs of respiratory distress um and then go through the conditions that have listed here. And then at the end, we'll go through some sbs just to consolidate your learning and those will come up as polls for which Jasmine will set up right, so bronchiolitis is gonna be kind of your bread and butter of the respiratory pedes conditions. Um It's basically an inflammation infection of the bronchioles, which are the small airways of the lungs and usually caused by a virus called respiratory syncytial virus that's the most common cause, but it can be caused by other other viruses as well, very very common in winter and in between the month of november to kind of february march time, A lot of the pediatric in patient will be bronchiolitis or a lot of the patient's presenting to a and E will be bronchiolitis babies um It's most common in babies under six months and can rarely be up to the age of two, particularly in ex, premature babies who have chronic lung disease, which will come onto towards the end of the presentation. Um Also if I'm going too fast or anything, please let me know and we'll slow down a bit and go through it just pop in the chat um kind of why it occurs in, in younger children is because their respiratory systems are smaller, and even when there's the smallest amount of inflammation in mucus, it has a very significant effect on the airways, ability to kind of circulate, uh circulate air through um the alveoli and back out again um and that causes kind of the harsh sounds which will go through in the next slide. Um Kind of the signs and symptoms you'd be looking at uh horizon symptoms, so snotty nose, sneezing, mucus um and then respiratory distress signs, which will go through next heavy breathing so difficulty in breathing, breathing first poor feeding, and reduced wet nappies because they're having poor feeding um having a fever, apneas, which is where the child has episodes where they stop breathing um and wheezing crackles that can be heard when you listen to this to the chest of the stethoscope. Um There's kind of a classic history of illness of the RSB and it usually starts with those kind of Coryza symptoms that snotty nose and all for a couple of days um half usually improves spontaneously from that and half developed the chest signs following, in the following 1 to 2 days, it worsens after that for the next three days with increased work of breathing um and all those signs that the difficulty feeding that reduced wet nappies, um and then the symptoms are the worst on day 3 to 4. Of that, it's kind of static at that point for the next three days and then in total last 7 to 10 days and they usually fully recover by 2 to 3 weeks time management wise, most most babies with bronchiolitis only require conservative management at home and it's just supportive. Um There are a couple of things that would make you want to admit the baby, so things like if they've if they do have significantly reduced intake, if they're dehydrated, the kind of observations that you see there so with a very very high respiratory rate um what I've done is and on the last slide, I've put the normal values for pediatrics as well because respiratory rate of 17, an adult would be very very alarming um So, I've popped those values kind of on, at the end, just for your reference um and then moderate to severe respiratory distress, any apnea episodes and if they have, if they're less than three months old and have a pre existing condition such as chronic lung disease of prematurity or cystic fibrosis. Anything like that. Um There's very little evidence for things like nebula saline bronchodilators, which are very commonly used in conditions like asthma um. And if they are admitted, the kind of management again will be supportive, just kind of the next step up, which would be um if they're not feeling very well orally, then maybe an n. G. Or an iv supplement um nasal drops supplementary oxygen if they're sat salo, occasionally ventilatory support, if it's needed um and one of the things to stop high risk babies getting bronchiolitis in the first place would be a monoclonal antibody injection called Pahlavi is a mob, which is very expensive, but it's given to um ex premature babies babies with congenital heart disease, those who are more likely to be at risk of contracting things like Rsv and having complications from that. Um If there's no questions at the moment, we'll go on to looking at respiratory distress in a little bit more detail, but first I would like you guys to, I'm not sure if you can unmee on this, but if you can pop in the chat what kind of features would you see in a child with respiratory distress that you might have heard of and just bearing in mind some of these are specific to children um So if you can get out any of those that would be fab, I'll give you a minute, minute, minute and a half to just pop anything you think of in the chat and then we'll go through them together good five getting some answers coming through wonderful, great you guys know your stuff, good, anything else or just give it a couple more seconds wonderful, we've got some great answers coming through and all of them are some of the ones that will be covering in the next slide, so that's great and we'll go through them now. So some of the signs I've got a video coming up for you as well. That Jasmine will very kindly share, um but some of the signs that you might see exactly like you said, take it mayor or a res, respiratory rate, things like use of accessory muscles when they breathe and that's when you can kind of see the recessions as well because they're using their their other muscles to help them take that air in, so the intercostal and sub postural recessions that you might see nasal flaring. Is you guys correctly identified, cyanosis, which is the low oxygen saturations trickle tugging um nasal flaring You might hear other terms like seesaw breathing, which is where the tummy goes out and the chest goes in and vice versa, which kind of shows an obstruction in the airway um and then we'll go through some of the sounds that you might hear as well, so wheezing would be um like a whistling sound was by narrowed airways, typically heard during exploration, grunting would be caused by exhaling with. With the glass is partially closed um and stride or is usually due to an upper airway obstruction, which would be a high pitch inspiratory noise, so if yasmin you wouldn't mind playing the video, mhm sure mhm, was it yeah, okay, yeah, uh uh okay, okay yeah uh huh like jasmine. Hopefully, you guys were able to see some of those signs, things like where the skin is being sucked in between the ribs um going underneath the ribs as well and things like nasal flaring and you could see some of those babies. Also had um nasal cannula and maybe because they were having episodes of cyanosis um and then you could very clearly hear some things like the wheezing and things like that. So One of the other very common conditions that you'll see um is croup um and this is usually caused because of um it is again an acute infective respiratory disease, um But this time it's an upper airway infection which has caused causing edema within lowerings, um kind of the key thing that you need to remember your SBA is is is caused by parrot influenza virus, although again it can be caused by others more less frequently like influenza and even RSV, which was the most common cause of bronchiolitis. Um I don't really have a way to remember how to distinguish between the two, but it's just something you have to remember because it's one of the most common SBA questions that comes up um It usually affects kind of older children than bronchiolitis, so, between six months to two years, um and it usually improves a bit quicker than the RSv picture did in bronculitis. There's some other important differential diagnoses that you need to kind of rule out before diagnosing group, so hepatitis would be one of the most important ones to rule out which will come onto um bacteria, trachea artis, which is a severe infection caused by group A strep or staph aureus, but it's very rare anaphylaxis, so getting that history is very important to see whether they've got they've tried any new foods or how quick the onset was to make sure that it's not an anaphylactic reaction um and they would also be presenting with things like hypertensive shock and stride or again in in situations with anaphylaxis symptoms. Wise you have the classical barking cough, which I will show you in the next video coming up um and it kind of occurs in clusters. Again, they'll have increased work of breathing dyspnea. Um They'll have horse voice and this time they'll have stridor, which is that upper airway obstruction noise, which is high pitched and they'll have a low grade fever again. Um If they have a chest x ray done, they might see something called the steeple sign on there, which is just on the slides. It's that kind of pointy nous towards the top can also be called things like a wine bottle sign or inverted v sign um and it's that tapering off at the top of the trachea which is highly suggestive of croup because of that kind of edema around the trachea. Um Yasmin If you wouldn't mind just playing the next video, uh uh oh all right baby uh uh uh Thanks jasmine uh So that was more just to show you kind of what that classical barking cough would sound like um and they might have features of respiratory distress but less likely than in something like bronchiolitis. Um Management wise, again is very similar to bronchiolitis with management at home for most children. Um fluids resting kind of stop, don't don't let them go to school to stop the infection spread. Um Some children might need oral dexamethasone and that's as a single dose of 150 micrograms per kilogram and can be repeated if needed and then if they require admission, they might need supplementary oxygen things like nebulized budesonide, adrenaline intubation, ventilation, but that's far down the line and is not commonplace to happen um and that would require then discussion with anesthetics and consultant pediatricians, so we mentioned epiglottitis as one of the differential diagnoses for croup and this is a life threatening emergency um What this is is inflammation and swelling of the epic lattice, which is caused by infection, which is typically haemophilus influenza B. This is now very rare due to the routine vaccination program and I would advise that you go away and look up that vaccination program um to see kind of when children are given what I know, it's a pain to try and revise that, but it does come up in exam questions. Um Exam Question wise, the classic history would be an unvaccinated child presenting with the signs and symptoms of hepatitis, which would be the fever, sore throat, sitting forward drawling, um muffled voice, a quiet child um and just generally looking quite unwell and they sit in this tripod position, which is sat forward with like a knee on each hand. Um to kind of help them try and get that air in the key thing with ethical otitis is that investigations should not be performed if the child is acutely unwell because the last thing that you want to do is upset the child because it could prompt closure of the airway, which is definitely not what you want if it's like an extra of the neck is done um. It, again this might be just for exam purposes, but it shows a a thumbprint sign which is where the dramatist tissue is kind of, is that shadow of the in the shape of the thumb that's pressed into the trachea um and of course the extra can be useful differential diagnosis wise to try and exclude foreign body as well. Um management like I said key thing do not distress the child very important to let the pediatrician and anesthetics know and always prepare for the worst case scenario, which is intubation. In case it's needed um and once the airway is secure, you can then go on to treat with things like antibiotics and steroids um if it's needed, but the key thing secure the airway first do not distress the child um just to mention as well that one of the complications that can occur after a hepatitis is an epic glottic abscess um which is kind of a collection of pass um around the epiglottis, which also threatens the airway. Again making it a life threatening emergency and treatment is similar to what we've discussed hepatitis, yes. The next thing I want is going through is pneumonia um so again adults can have pneumonia. Children can also get pneumonia. Um It's just an infection of the lung tissue which is more focal um and involves inflammation and spit and filling in the airways and the rv a lie. It can be bacteria, viral, atypical bacteria, very rarely fungal um and the most common kind of causes of bacteria would be strep strep pneumonia um hip again in, in the unvaccinated child, and group b strep, which would be contracted during birth, but the most common one to remember would be streptococcus pneumonia viral wise, Rsv is the most common and then again parainfluenza virus and influenza also there in the spectrum of viral infections. Um signs and symptoms very similar to what we've heard already, cough, high fever, tachypnea, tachycardia, hypoxia, hypertension would go along with tachycardia If there were signs of septic shock, um increased breathing work can be acutely confused and very tired, um and then things like on the examination, you'd hear bronchial breath sounds, focal course crackles because it's in one area um and down as to percussion. So that's those signs are very similar to what you'd hear in an adult chest and the chest x ray is kind of the investigation of choice, but it's not routinely needed um but as you can see on the chest x ray, there would you be able to describe to me what you see on that. In the chat, I'll just give you a couple of seconds her pictures big enough for you guys to see it, have a guess, any anyone can pop anything in the chat, just give it a go and see what say what the main thing is that you can see yeah wonderful good um So, I've got some answers coming through, I'll give a couple more seconds if anyone else wants to give it a go um and we'll go through the other investigations and then come back to that. Um sputum cultures and throat swabs for bacterial cultures and viral pcr really helpful. Um You kind of take those they take a while to come back um So you give broad spectrum antibiotics first, but they can help later on, guide the treatment that you would need. Um I had a very similar case of this in my husky um and I forgot to say the sputum cultures and throat swabs and viral pcr, but it's it's just one of the things that is often forgotten when you're going through the investigations that can be done um blood cultures if you think patient's septic um and then papillary blood gas can be used for kind of measuring respiratory or metabolic acidosis. Again, if you're considering whether they're septic or not, um So, you guys who replied in the chat, you're very right, there is a right to upper middle uh right middle too right upper lobe consolidation um and yeah that would be kind of indicate indicative of a focal pneumonia. Management. Wise you look at the antibiotics according to local guidelines, which I know isn't very helpful of me, but the app micro guide can be used to look at your own hospital, local guidelines um generally speaking amoxicillin can be used first line um and you can add a macrolide along with it whether macrolides can be used as monotherapy in patient's with a pencil in allergy. Remember you've got to start steps to six for patient's who you who look septic to you um and again getting early help with pediatric consultants and and your seniors will be really helpful you have the kind of experience to just look at a child and say yeah that child doesn't look very well um Pediatric patient's are different adults in that they can be well well well and then suddenly drop off, whereas in adult patient's, you tend to see kind of a more gradual decline um so getting that senior help early will be really helpful for you to kind of get that management started um and of course maintaining your oxygen saturation is above 92% so supplementary oxygen as, and where needed. The next one I'd like to go through is viral induced wheeze, which is essentially an acute wheezy illness caused by a viral infection um Again can be caused by things like rsv, rhinovirus and it's it's similar in fact that it's it's inflammation in the dema, within the airway, which causes release of mucus and causes narrowing of the airway causing uh restriction of space for air flow. Um You can hear that wheeze and it can lead to respiratory distress and certain children can be more prone to it um For example, um those with uh those with a family history of it. Um There's a possible hereditary elements are asking about brothers and sisters and whether they've experienced something similar um And those children are at higher risk of developing asthma as well. Um signs and symptoms are very similar, so viral in the illness, shortness of breath, some signs of respiratory distress as possible and then the expiry torrey weeds throughout the chest would be heard and focal weeds would be more indicative of something else like a inhaled foreign body or a tumor because it would be that focal airway obstruction, So again this is where your examination skills are really really important. It can be difficult to tell between viral induced wheeze and acute asthma because they both cause this wheezy picture um. And it's not a definitive distinction, so again asking seniors for support, asking for help to kind of distinguish because they've got their experience. Generally speaking, um asthma is difficult to diagnose in children younger than about five years old. Um So if if you see this picture of of a wheeze in those below three, um it's more likely to be a while and used we'd rather than acute asthma, asthma is also usually associated with like an a. To b. History so things like hay fever uh asthma um that kind of history would go along more with the asthma picture rather than do viral induced wheeze um. And then asthma is more common place to be seen when it's triggered by by something um so for example, exercise, cold weather, um and we'll go through that a little bit more in the next side management for both weiland, juice weeds and acute asthma at the same, so we'll go through that now, but it's just kind of making that distinction between which one it is and looking at those features of how what kind of the demographic if the child is um to see which one is more likely so just going through asthma um It's it's caused because of a uh sorry my screen just gone. Oh I don't know what's happening there oh it was back sorry um The acute asthma is kind of uh acute deterioration in what is the chronic asthma picture. Um We'll go through those kind of chronic symptoms in the next side um and like I said it's usually triggered by something acute um so infection, exercise, called weather and even things like strong emotion can be can be a trigger for some children, signs and symptoms would be progressively worsening breathlessness, tachypnea, again signs of respiratory distress uh and expiry tory, wheeze again heard throughout the chest rather than in one focal area, um the chest can sound tight with reduced air entry or can be silent, which is a very, very poor sign um and if you look at the table, it shows you kind of how we distinguish between mild moderate and then severe and life threatening asthma. Um It's a bit of a pain to have to learn these figures, but it does come up in exam questions, um So things like a silent chest or exhaustion um would be very poor signs and would need much more escalation than something like if they've got a wheeze, but they're still feeding well, are a bit breathless and they're satisfying. Um It really does help to kind of prioritize your management depending on the severity of the asthma attack that they're having management is quite a lot for acute asthma cases um as it is for chronic asthma cases and there's a step wise approach to the chronic management, um but going through you do your whole a. B. C. D. Assessment. Um you would start them on things like supplementary oxygen if they, if they sat to lower than 94% use bronchodilators, and you'd step it up as inhaled or nebulized nebulized is usually used. If they, if they are also having episodes of uh diagnosis, so their stats are going less than 90 92%. Um There's uh I was uh an emergency pedes talk yesterday that said that there's there's if the patient's not requiring any oxygen, there's no real difference between using the inhalers versus using nebulizer, salbutamol, so the nebulizers would be more used if they're also needing that supplementary oxygen. You then also give the ipratropium bromide, magnesium sulfate and aminophylline would come as you escalate further towards i. T. U. And anesthetics um and then you'd think of giving things like steroids as well as antibiotics if there's a bacterial cause that's infected uh that's if there's a bacterial cause um suspected, sorry, um and then on the right hand side of your slide, you can see that there's kind of a step wise on mild cases to moderate and then severe life threatening you would need to urgently call anaesthetics as well as pediatrics because intubation and ventilation is needed, especially when signs like exhaustion of, seen because the child is just not getting that oxygen in that they need and they might become confused, agitated, and so tired, that they're not able to hold their respiratory effort any longer. Um I'm gonna I'm not gonna go through the kind of the dosings and stuff because they're all on the slide um feel free to review at a later time um going through the chronic management or chronic presentation of of asthma. Um It's basically caused because of uh inflammatory uh response to a trigger and that smooth muscle response to the stimuli by constricting and causing airflow obstruction um and then there's increased mucus production, which then further causes the airways to contract and it's kind of like an ongoing cycle um and it's usually like I said associated with other other conditions like um eczema, hay fever, which is kind of the atopic triad um as well as food allergies and tends to run in families. So again it's very important to ask about family history signs and symptoms with chronic asthma. Uh things like episodic symptoms with those exacerbations because of the triggers and families might be able to to identify what kind of triggers um cause the child to go into having this kind of attack. Um There's a dry cough that's usually associated with the wheeze and shortness of breath. Um There's uh again family history bilateral polyphonic weeds can be heard widespread throughout the lungs um and then you've got this thing called bronchodilator reversibility, so symptoms improved with bronchodilators. You might have heard of a term called diurnal variability, which is where it's worse at night and early in the morning and the graph on the right hand side kind of shows a peak flow diary um so you can see in early in the morning, the peak flow kind of amount that they can blow into into that is much less than what is in kind of the early afternoon um so it tends to be worse uh late at night and early in the morning. Um investigations um are there many fold for asthma and things like the diagnosis for younger children is typically made from the history and sam um like I was saying earlier things. When comparing with something like viral induced wheeze, it's more likely to be that in younger children, less than three years old, um older than three, you're kind of going into the territory of asthma um and then confirm confirmed diagnosis usually after the age of five. Um When there's a low, when there's kind of like an intermediate risk of asthma, you can use a trial of the bronchodilators and see whether that helps their symptoms um. And then you can use things like spyrometry um the f. E. N. O. Test, peak flow variabilities to doing that peak flow diary um Those would kind of be more specialist investigations that you would do so you'd refer them and then and then consider doing those investigations. Um The management of asthma now is, is different depending on which guidelines you follow, so I would suggest that you look up with your university, your your trust, or whatever to see what guidelines they follow the ones that have popped into the slide here are the BTS guidelines, um but there's subtle differences between the nice guidelines and if you look on question, banks like pass med and things they might be again slightly different to that. Um Again, I'm not going to go through the management of chronic asthma in in depth because the stepwise approach is quite clear, um One thing that's uh that's quite important to go through is is if they they have an acute attack and they've they've been admitted with that. Um you need to discharge them with a personalized asthma action plan which would be part of kind of the more chronic management side of things um that's an individual plan per patient depending on what what they're acute admission was with um and then they need appropriate follow up following the acute attack as well, so things like um safety Netting information, they would need to be followed up by their gp um and usually after an acute attack, they would um they would need to be monitored for kind of 48 hours, depending on how much salbutamol they've needed during their admission, So the chronic management goes hand in hand with the acute management um and that personalized asthma action plan is very important and just ask is wise it's really um it's quite nice point to put forward is one of the conservative management points um and it shows that you're looking at the patient holistically as well, um so that's quite nice examiners like it when you say things like the personalized plan for the patient. Um we're on to one of the last two conditions and we're nearly there um so we're getting into the slightly more um kind of niche topics, but they still do come up in exams um so cystic fibrosis um very important to remember. It's an autism more recessive condition um Very common Sba, questions come up um and it's because of genetic mutation on the cftr gene, which affects the mucous glands. So along with the respiratory complications, any any part of the body that produces mucus is also affected, So the gut, the pancreas, any kind of secretions are affected and the so going through those the thick pancreatic and biliary secretions that are producing cystic fibrosis cause block ducts, which reduces the digestive enzymes um and then low volume thick airway secretions means that there's reduced clearance within the airway, making them more susceptible to bacterial infections and those colonized the alveolar line cause things like pneumonias make them more susceptible things like that um as well as more susceptible to viral infections as well, um and then you've got the uh congenital bilateral absence of fast deference, which means that there's no route for sperm to go from the testes um which causes male infertility, so the signs and symptoms kind of go hand in hand with that things like loose greasy stools because they're not able to get those pancreatic enzymes out, abdominal pain, and bloating again because of uh inability to digest food because they're not getting those enzymes, recurrent respiratory tract infections, chronic cough, thick sputum um that they continuously have to clear um and then some of the more niche symptoms um Poor weight gain and height gain, which is called fairly to thrive might be seen um as sign as a sign in kind of growing neonate. Um things like figure clubbing, nasal polyps, these are kind of more sba, question types um and then as a new born meconium eilis is often the first sign that you might see for a child with cystic fibrosis. Um Investigations wise you all babies have a the heel prick test or the newborn blood spot test, which is done very shortly after their birth um and picks up on most cases of cystic fibrosis, but the gold standard for um for diagnosing cystic fibrosis would be the sweat test and the value that you're looking for is a chloride concentration of more than 60 millimoles per liter. There are also kind of genetic testing um sources available um prenatally, So things like amniocentesis or chorionic villus sampling, um but they're not done very much um and remember the gold standard is the sweat test. Um Management wise is an MDT approach for all of the different parts of the condition that could be going on, So chest wise, you would need chest physiotherapy to help clear that mucus um prophylactic flu, cloxacillin reduces the risk of staph aureus because that's one of the most common colonizers um and there's a little red sign, uh note at the top that says the most common ones to remember our pseudomonas and staph aureus pseudomonas being a particularly difficult to treat infection in patients with cystic fibrosis um treating the chest infections when they occur, giving bronchodilators to treat the broncho constriction that they have, um and then vaccinating them regularly against pneumococcal influenza and varicella um and then for kind of the more digestive side of things you've got high calorie intake um korean tablets to help digest those facts um that are missing with the the lack of those pancreatic enzymes um And then just generally, things like exercise, um there's something called dornase alpha which you might have heard of, um which is an enzyme that helps to break down um dna material in secretions, which makes it a little bit easier to clear um and then other other management techniques would be things like um nebulized saline and then further down the line you could consider things like lung transplantation or liver transplantation and fertility treatments for older patients with cystic fibrosis and then counseling um for when they want to have children of their own. The last condition that we're gonna go through is chronic lung disease of prematurity and this might be covered in kind of a neonatal session as well, but um I'll go through it quite quickly again because it's quite quite niche topic and it's also known as bronchopulmonary dysplasia occurs in premature babies. Um typically those born before 28 weeks um who might have suffered any kind of respiratory distress syndrome because they were premature babies um and those who might have needed oxygen therapy or intubation and ventilation when they were born and sounds and symptoms would be hypoxia or uh cyanosis, um increased work of breathing, dyspnea, um poor feeding and weight gain crackles, and we've um and again they're susceptible to infections um similar to babies with cystic fibrosis the best kind of thing to prevent uh to prevent chronic lung disease of prematurity and prevent babies going into respiratory distress syndrome. If there are signs of premature labor would be to give the still pregnant mother a dose of corticosteroids so something like betamethasone would be the most effective thing and it speeds up development of the fetal lungs um and reduces the risk then of bronchopulmonary dysplasia. Um Once the baby is born, If they do have um any risk of chronic lung disease of prematurity, you can use things like cpac, caffeine um make sure you don't over oxygenate them um to try and prevent that that um developing into the chronic lung disease of prematurity. Um diagnosis can be made also using chest x ray um management wise you you can do formal sleep studies and babies discharged from the the neonatal unit, can also be given a low dose of oxygen at home to continue, which is then weaned off during the first year of life again similar to the way I mentioned before the Pahlavi eczema injection is very important in uh ex, premature babies to try and prevent their risk of getting things like uh the risk of getting RSv because such an infection. If they do get bronculitis with RSv, it could be much more um dangerous for babies who do have chronic lung disease of prematurity. Yeah just before we go on to the SBA is, I know that was a lot of information um does anyone have any questions before we move on. Um I'll leave that sda up and if if you have any questions pop them in the chat, and we'll try and go through them um and if you can just give your answers as well. Uh huh Jasmine if you could just let me know when most people have answered because I can't see that yeah I will do cool. Thanks, so para influenza is currently wedding, but um there's wait for a few more responses okay, oh I can't see them sorry about that. I think they were in the child, so yeah I got it give it like 10 more seconds, then we'll go through the answers cool, so going through this question amazes, a one year old girl brought to the gp. Her mother says she's been unwell for a few days with a fever and has an odd sounding cough, which sounds like a buck um which is the organisms, is more likely to be the cause of mazes, illness. Um A lot of the time, universities like to give these to step sba, so the first thing you have to work out is what condition she's got and then the second thing to work out, which is what the questions asking is what would be the causative organism um for this condition, So as most of you recognize the right answer is parainfluenza virus, so poor, little mazes got croup going on and she's got the spark like cough and the most common cause of group would be parainfluenza virus um Rsv with most commonly causes bronchiolitis, strep, pneumonia, causes pneumonia, micro plasma is one of a typical causes of pneumonia, and varicella zoster virus, varicella zoster virus is a bit of a rogue answer. It causes chicken pox good, well done most of you um and for the others who put rsv and do not worry because it's like I said it's there's no kind of way that I've been been able to think of to distinguish between the two organisms that cause um parent uh that cause croup and bronchiolitis, most commonly, rsv does cause group, but the most common cause would be uh parainfluenza virus, okay. I'll just give you guys a couple of seconds to answer the next s. P. A. Oh, got a bit more of a split going on this one give it a couple more seconds just for anyone's answer who hasn't had a chance to okay 10 more seconds cool, so we've got a split going on between life threatening asthma, anaphylaxis, moderate asthma, and severe asthma, and I did tell you that I hate these questions, where it asks you which classification it is because it's a nightmare to learn the values, but in this case, Raj was suffering from severe asthma um just going through kind of his um presentation initially, um he is short of breath, which is affecting his ability to eat um So that already excludes out kind of the mild moderate category because in that one they're feeling well and talking in full sentences, and it also says he's unable talk in full sentences and using his kind of accessory muscles to help him breathe. Um So we've ruled out moderate asthma. Um doesn't sound like Ryland used weed because he's not got any history if this kind of kerasal symptoms or anything like that and it's been brought on quite quite quickly. Um So no one put viral induced wheeze down anyway, so we've ruled out a and d um with anaphylaxis, it's less likely because there's no kind of history of uh in a question like like this, if, if it was anaphylaxis, you'd have um something like he went to a restaurant and ate some uh egg product that um he then had an acute reaction to had a rash things like that you get other signs like that and it would be more likely to come on because of something like a food trigger or something like that um and then we've now been left with severe and life threatening asthma. So these two are probably the most difficult to distinguish between um but looking at his observations, his respiratory rate is uh over 30 it's over 30 his sats are just below the 92%. He's a bit tachycardic. Um There's the wheeze heard, but he's not got anything like a silent chest because you can hear his wheeze on auscultation. He's not got any signs of exhaustion. Um Haven't put any values for the peak flow rate because it can often be difficult to get children to comply with doing the peak flow rate um So if we're just going on on the, the other factors, um it's it's more likely to be severe asthma because of the kind of not the picture of the silent chest, the poor respiratory effort, the consciousness being able to confusion um hope that makes sense if anyone has any questions about that pop them in the chat, and we'll go through it again, yeah sba three, but halfway through the sba s good, Getting some mountains is coming through, you have 10 more seconds and then we'll go through the actors okay, so majority, if you got this right and the first step that you would need to do is alert the pediatrician and and anaesthetist. Again, this is one of those two stage sba s, um so can you guys put in the chat what the diagnosis would be with the symptoms that he's having like a muffled voice makes a funny noise. Mostly you've got the answer right, so you must know what the diagnosis is good wonderful, So you're thinking Africa, tightest it's an emergency you got to let someone else know, so you need to alert pediatrician, anesthetics and full examination of the throat is not a good idea. You don't want to be poking around their throat because if they start to cry and they've come out of distress, it might close their airway um and then things like that the child is unwell. You wouldn't really do a neck x ray um but just for revision purposes. Do you guys remember what the sign would be on a neck neck x ray. If you were to do one, I'll just give you like 30 seconds just to pop in the airway just for for revision and then things like IV antibiotics and steroids would be once the airways secure you'd think about doing stuff like that, but this child is acutely unwell wonderful, thank you very much you know for your lovely answer. Um It would be thumbprints I indeed on the chest x ray um and because this child is unwell at the moment, he's got that classic drawling the tripoding um he's not been vaccinated, so you're you're very suspicious that he's got haemophilus influenza B causing this epiglottitis um So you'd need to alert someone we're very nearly done two more sbs to go, so you've got little molly coming in to the g. P. Surgery for a general checkup because she's moved to the area recently um And she's uh an x premature baby born at 28 weeks. Um Her mom can't quite remember the name of an injection that she's been getting um but she was told it helps kind of stop the cough that she might get um because she's ex premature she's at higher risk of getting this cup, so what should the gp prescribed is this injection. I think we're waiting for three more people who I hope haven't left, I'm sorry we've run over a little bit you have 10 more seconds then we'll go through okay, so the answer we're looking for here is Pahlavi zoom ob, which we discussed in the main body of the presentation. Um It's one of the monoclonal antibodies that target rsv and it's given to high risk babies, so those who are ex premature babies um those with congenital heart disease, cystic fibrosis um things that would cause them to be at higher risk of developing complications from our form and rsv infection, the others are just random like monoclonal antibodies and dexamethasone just there. Um so trans twos mob is one of the, is also known as herceptin for breast cancer. Dexamethasone, used an acute treatment of croup itaru, zoom ob is an antidote to the bigger tran, and infliximab is one of the other monoclonal antibodies used for things like rheumatoid arthritis and ulcerative colitis, so kalamazoo mob is the key thing to remember for high risk babies to prevent them getting rsv last sba, guys and then you're all done Aisha and hamish are practicing for their exams and they're discussing what the gold standard is for cystic fibrosis. What should hamish reply to Aisha as the gold standard for diagnosing cystic fibrosis. Good. I think we've got a consensus generally, we'll just give it a little bit more time five more seconds, yeah we've got 100% on this one, so although all of these tests can be used um the diagnostic test is the spec test um and the number you're looking for is a chloride concentration of more than 60 million miles. Um The other ones can be used so things like prenatal coronate, but cvs and amnio synthesis can be used um newborn heel prick test or um the blood spot test is also known, as can be done um for, is done for all children at birth and picks up the most cases um and then chest x ray is not not really used that can be used if they've got like an infection, got an acute infection going on to see if there's a focal pneumonia that is me all done um just some useful resources. There's the Pedes book. Um Some people know it's like the Sunflower Book um and then there's zero to finals, which is what I've used for most of my information um. And then these are just my references and I am happy to answer any questions. If you have any, please, please provide me with feedback. I would be very grateful, thank you that was amazing, get pre. I love the Sbs at the end good. I'm glad it was helpful um I've sent the feedback link if anyone's having any difficulties, let me know, but it should be quite simple and you get certificate at the end and also gives you a pretty feedback, which he needs so pleased. Um Also um the dead about hospital guys have my contact details and stuff, so if anyone has any other questions um feel free to to drop them an email or message or whatever they'll just pass it on to me, um I'm happy to take any any questions if you have them now as well, apologies again for running a little bit late at the start, um we're not really sure what happened.