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um um onset. My name's Michelle. Can you guys do a quick Yes. And then try and you can hear me. Cool. So you're welcome. Um, so today is and it's a continuation off our files. Easy, Siris. It's going to be part you of pediatrics. Okay, so hopefully along you would have turned up on Tuesday for part one. We lessened your movement, went to eat after cardiology and EKG actress gastroenterology as well. Today, uh, in part in the first half of the recession, I'll be taking you through pediatric respiratory conditions. Okay. And And the second half will go through pediatric infectious diseases and remind pulls. Deliver that section again. Hopefully with this holes or to park it affects ears will cover a lot of the high you'll contact. You guys need to know for finals in terms of pediatrics. Okay, It's only it's extensive coverage of the specialties, but we picked the specialties because we felt these are really high. Um, impact specialties, stuff, examples. Love to test students on in terms of pediatrics. Okay, but to cover the entire two of pediatrics in a Susan, world knows it's very extensive. It's always a huge specialty So we selective in which specialty is We went for pulmonology and arms, but for clinical practice. Okay, you guys will see a lot of pediatric respiratory conditions. So obviously very important. Very high impact. Very. Um, um useful sexually, you guys. So let's get to it. So the the Avonex is a very wide spying specialty, but it's how you were warding specialty. Get you in with kids. Helping kids very rewarding specialty and learning knowledge in pediatrics is very important. Disease is back. Children in very different ways to adults. Okay, everything is new in pediatrics. Okay, I often I feel like to pee and pee after it's probably you need to spend another couple of years of medical school because this is so much in pediatrics approaching pediatric patients can be quite Don't think. Okay. And you have to be confident and your knowledge off, um, pediatric conditions, because it could be very dominating to do with Children. Okay, dealing with parents as well. It's important to be confident in your knowledge and also, like, even said, I'm gonna have ah, a couple of videos and pictures off babies to stay invasive with various different response to pathology. So just get you have been warned. It's mainly just to help your living on be a So we're gonna talk about pulmonology. And I want to just get some basic facts about Pediatric airways at the way, because this is important and very tentative elements. So can you tell me some key differences between a pediatric away Onda adults airway? Which means which makes it, which makes Children more likely to get breathing difficulties in general? What makes a pediatric airway difference? What's what makes them more vulnerable to getting breathing difficulties? Can you guys let me know the job? What makes it child more vulnerable to getting breathing difficulties or smaller gets okay off the nasal? Breathe Very good. Some message. Floppy so good there epiglottis is very floppy again. The very vulnerable to getting demonstrates and causing obstruction. Secretions. Yes, ability, very important is very, very seven on a topical and physical physiological reasons for it. So let's go through that I've had I'm gonna have, like, a really important one. So, firstly, in it, like boots on said, infants have very small airways. Okay, so if you guys remember your risperidone physiology, any increase in um, I would resist any narrowing in an airway, least to a significant increase in airway resistance. Okay, it's like classes will so infants naturally have very small airway. So if there's anything that causes further narrowing off the airway, and he's a big increase in a resistance, okay, so that's very important. Thing is last. White Children's actually very vulnerable. Teo getting away obstruction that I were narrowing and getting breathing difficulty because of its and also, as someone mentioned, infants are primarily nasal breathers. Okay, that all the get nasal bring this okay, that can breathe through the mouth, but it's mainly nasal breathers. Okay, The reason for that is hopefully it's obvious infants by being nasal breathers that gives them an advantage for when they eat. Okay, obviously, if they having to breathe through the mouth and eat at the same time, that has risk of aspiration. Okay, particularly goes. Infants on would be as able to eat on breathe at the same time with their mouths. Okay, so being nasal breathers, that gives them an advantage. But it also means that they're at the increased risk off problems to do with work of breathing, because anything that blocks don't notice any kind of secretions. So anything that trucks the knees or firings that's going to significantly increase the work of breathing. Okay? And I said, That's an important reason why it's very important in pediatric patients to constantly thinking about These are suctioning things. Secretions have an MG tube in full feeding on your lights, and they get breathing difficulties. You might want to consider taking them out because most of the breathing happens to their nose. Okay, so it's a very important, clinically relevant facts to you. You wear off and finally, and another important factor. What I want you guys to be really fair about is that crying baby is a bleeding baby. Okay, if a baby is crying, it means that the airway is patients. Okay. Even though the baby crying means that might be in discomfort, it's only is that breathing? Okay, that's an important thing to just recognize clinically. Okay. Okay, so we have a bunch of single best answer questions. Do you guys have ago someone from the team can, uh, to control the post beating it? I'm sure I'm sure a lot of you will find the SPF today. of it is. Yeah, purposely made them a bit easier just because I want to make sure everyone's got a lot of the basics down in pediatric respiratory conditions. Just because it's such an important specialty practice as well as finances. Well, kind of thing that you got. Yeah, you guys got the correct answer. This is our son of it, but, um, straightforward clinical SBA for you guys, but yeah, correct answer. Here is something that the auction with continuous pulse oximetry monitoring eso Can you guys let me know in the chart? What is the most likely diagnosis? It? What's the most likely diagnosis is big bronchi like this. Statistically is probably the most likely diagnosis because it's the most common pediatric respiratory condition. But yeah, So this is bronchiolitis, okay? And we're you know, we're going to really nail down bronchiolitis because it's a super super important condition to know what's in practice. It's the leading cause. The hospital admission in infants, very important to have a good understanding of bronchiolitis. So sound one, though he got breathing difficulties. Okay, Recent history, breathing difficulties, difficulty feeding rhinorrhea and has a past wet naps for the past. For lows. Okay, so difficulty feeding. No passing out. Not these. These are red flag symptoms in a pediatric history. Okay, No passing. What? What not is for 12 hours is definitely a big red flag. Okay, remember, baby should generally pass around five or more soaking wet, not piece per day. So that's that's a big red like on. We're gonna really holding on these examination findings. But these are all important in my examination findings off especially distress. Okay, So cost of recessions, trachea or tugging on increased work of breathing. So there's these are all important examination findings to pick up on and be in infants. And we're really I'll show you a lot of pictures to describe all these different findings which are pointing towards the spiritually distressed in pediatric patients on diffuse we's in both lung fields. That's another characteristic finding off bronchiolitis on. Also told you that the patients saturations are lowest well, so and you need to maintain such both sort of 92%. So you need oxygen. And the key thing I want to get with the management of bronchiolitis is that it's completely support supportive care. Okay, It's all about supportive care with bronchiolitis that we don't have any really good treatment off effective treatment options where it's all about supporting the influence, helping the child overcome the bronchial like this infection themselves on. There's not a lot of there's no evidence to do for things like nebulizer beautiful. No evidence for antibiotics. No evidence for cortical steroids. No evidence for things like hypotonic saline. It's all about supportive. Can bronchiolitis. Okay. And tests actually state it doesn't form part of the diagnosis. You might do a chest X ray to rule out other other different jobs. Buts. Auction is that means they would be the most appropriate answer option here. Next question. Still on the topic of bronchiolitis Have to go. Yeah, Like I said, our space RSP ST most difficult. The most common cause it'd organism off bronchiolitis. And we'll talk about that. Yeah, I think most of you got this one. This is again, if you know what this is that more of if you know what, you know what kind of question, but yeah, let's go through this. So you went from a and that is the correct answer. So happy Lizama. Um so let's go. Let's go through this. So we have a eight month old girl with a history of petroleum Fellows got features off from cure litis on. She was born on preterm. 29 weeks of gestation. So especially basically asking which of these agents can be given as prophylaxis against bronculitis. And the correct answer here is populism. Observe families lab. It's an anti monoclonal antibody is a monoclonal antibody just given for prophylaxis to reduce the risk. This. Can you tell me who gets, uh, populism? Um, does every single baby yet have a list? Um, it's a have These have been shown to reduce risk breaks off Bronco risk of bronchiolitis, but who actually gets it? Yeah. Premature. They have underlying respiratory diseases. Good beat. Um, Yep. Cardiac disease is a congenital sign off the carpet. You just get so basically, family is, um um is a very expensive drug. Okay, You know, it is very good at reducing risk of bronchiolitis. It's very expensive. So it's not that every baby gets said it. You these were at high risk of getting bronculitis are giving it, for example, preterm. Um, premature underlying heart disease patients, um, 100 underlying lung disease stations is what? Yeah. So let's talk. Okay? I've got a lot of us Spot diagnosis A. So we're going to talk through the different signs of respiratory distress. And I got a bunch of videos to show you s I want you guys to have a rewatch of the videos and let me know what comes to your mind clinically as a sign of respiratory distress. So hopefully these videos play okay? Yeah. You guys let me know the junk where you guys think this is a more of a general future. What would you thinks about that? This baby here, but that again, right? Yeah. Right. Okay, so it's a croup. This's instructed to be honest with this one, I was only getting as a general picture. This is, uh, just took it general to kidney. Yeah, that's what I was getting out with that one. But we'll talk through some more specific science in a bit. Uh, let's look at this one Trickle talking. Very good. Okay. Citrical talking. So it's a any super centrally a sign of respiratory distress. Sign of baby upper airway obstruction. Okay, so that is a drink you're tugging. Get good. How we look at this one. This one has a couple of difference as a couple of different signs. Yeah, there's a recession to him. But there's something else I want you guys to pick up. Very good nasal flaring. Okay, that's a really important one. I wanted to show you other videos off receptor it of retractions, but the one thing I want you to pick up on is the nasal flaring. So again, if you look at the nose, the nasal flattest, see the nasal flaring see the nasal nose to pass it, nasal passage opening up. So that's something I really want us to pick up on. So that's, um, again, it's a sign that the baby's trying to open up another out, trying to increase the airway passage because, remember, babies, primarily nasal breathers. So they're trying to open up the frank fate and alternate passage for explosive. That's the nasal flaring. Okay, again. Sign of respiratory distress. Uh, I would look at this one. Okay, again, we get single. This one head bobbing. Good. So again, sign of respiratory distress. Essentially, uh, essentially babies using their neck muscles to try and increase that interval space time create increased negative interphone pressure to increase tell with the breathing, but because the neck muscles are not able to probably support the head that the actual extensive muscles had bumps again. Sign of experience. You distress someone said head down and seeing it that yeah, the baby's not listening to music. This is a sign off misprint. Tree distress. Uh, last one. This is just a picture. What This picture indicated Sinuses. Very good. Central sinosis again. You see the sign of skin, The discover bluish discoloration of the skin. Scientist. That's very good. Uh, yeah, he's got a couple of more videos for you guys. Have a look at this one. I don't know how well that projected, but, uh, I'm afraid again, anyone ever get any and see us what was happening in this baby? Yeah. Good. Desperate sessions retraction. And so that's some cost over a traction. That's what the That's what was happening there. Um and what about this one? And we'll see what's happening. I don't know if my videos pictures are lagging. I'm sorry if it is so I'll just play it again. In case if it is a people are able to see it? Probably so. The midday I'm going get us. Didn't. If you look closely at the chest, there's intercourse over production. So it's a bit different to the subcostal retractions with this one. So, yeah, that was the intercostal attraction. So this is some cost of attraction. This is intercourse of attractions. Essentially attractive attractions in a baby is indicating the baby's basically retracting. Teo overcome airway narrowing. So they're trying to increase the intrapleural different. Create more negative pressure inside the chest cavity to try and increase the amount of air that can come in. So and they retract in different places, depending on where the obstructionist. So of course, the attractions intercourse. Um, attractions. Okay, finally we got Now, wait, the These next ones are more about listening. Okay, So listen to the sound and tell me what the sound indicates. Eso. But if you guys have a listen and tell me what you guys here, right? Yeah, this isn't grunting. Um, that barking cough. Now, this is that this one was just a week's. Okay? This one was just the weakness. Uh, yeah, that one was just the wheezing. Have a listen to you big to wheezing. Sounds very. It's a very musical term. Okay, that's what the typical this with the sounds like it's very musical polyphonic. Okay, that's what we're thinking about. Typically expiatory I look at this one. This one is a very important sign to never miss. Okay, this is a very important one to pick up. And I haven't watched the video and have a listen. Is one right? Okay. No, no, it's not straight up. Right? Okay, okay. Someone said someone said it before. This isn't croup. Uh, this isn't the barky cough for thinking about. This is something else. Yes, I want that grunting Brunton. Very good. I'm not trying to come up with diagnosis specific diagnosis. I'm trying to describe the actual features. Become really diagnosis based on the video, say, but trying to pick up on the actual feature. So this is grunting. Okay, if you listen to get this So essentially, uh, grunting. The babies are clue arrival to create increased that pressure inside the albuterol. Like to keep them open. Okay, It's just Sinuses. You see it And things like epicortex, which we'll talk about doesn't There's another one. There's another sign of this baby I want you guys to pick up on What? What is the baby doing in terms of its posture? Okay. What What's the baby doing in terms of its posture to try? And but it's working. Breathing tried. Morning. Very good. So it's extending neck out. Chin out. Okay. Trying to increase strayed. Nice. Also that eight airway passage. Okay, that's what the Sinus. So this is two sides of grunting and tripod position. Last one here and then we'll start talking about all the clinical stuff watching this video. Okay? Yes, I'm a listen whistling. It's This's, uh this is what people mentioning before. Yes, Rider. I guess the honey pitched sound very characteristic. I don't know how well people able to hear it. I recommend just going on YouTube and listening to sounds a strategy. Okay, It's a high pitched general. Usually it's an inspired to sound. Okay, It can be exposed to the you can get it by you get both in to poetry, and it's inspired me an expected, but it's typically an expired in spite of me. Some, uh, also in there in the video, if you but you might have seen some retractions as Well, in some, uh, abdominal breathing as well. But the big thing is the striver. Okay, so if you weren't able to appreciate it, just go on YouTube. Listen to the sounds very important. Critically. Okay, so that was, um, strident. Okay, so that was a quick run through a bunch of different videos. I hope that was, You know, you get the guys, and I will just run through some single best answer questions. But this is a slide off all the different signs of respiratory distress in infants. Okay, we talked through most of them. Okay, This is very important for clinical practice in pediatric patients. Okay, if you take away anything from my session, just learned this list. Okay, Be able to say this list off the top of your head on down because this is very Clinton relevant. Very important to recognize that babies. Okay. As a general, as a general means of rule, things like Strider trade deal targeting super typically retractions. These are all sort of signs indicating sort of more operable way obstruction. Okay, uh, things look intercostal stuff, cost attractions, wheezing. Try putting it. Every morsel jested off lower airway obstruction. Okay, as a general. Okay, but the key things you want to be realizing it's not the baby. The infant is in respiratory distress. Okay, so it's somewhat bronchiolitis, so just that's what we're talking about with the first two s p S o. Again, it's very important. It's an epidemic in hospitals. You you see it all the time, especially during the winter months. Okay, Between sort of November in February, very common and hospitals. You see it all the time. If you go into a emergency department again, is usually caused by RSV respiratory syncytial virus. Although there's other causes well, again, we talked about risk factors. So underlying lung disease prematurity, um you know, deficiency, congenital heart disease are all important risk factors. Okay, because these are these mean the babies are at high risk of getting bronculitis at. These patients are indicated to get populism up. Okay, So the the vaccine, that anti monoclonal antibody that will reduce the risk of again then going on to get bronchiolitis on also a very useful nice fact to remember is that usually occurs after three months because initially in those initial months, the paternal antibodies gives protection passive immunity the remember idea. Cross the placenta. So the maternal antibodies are give passive immunity in those initial months. But most babies with wrong cholitis get it between 3 to 6 months. Okay, remember, You know, you know, when you see the bronchiolitis after one year, Okay? Bronchiolitis is a disease that affects Children below the age of one year. Uh, clinical features. So we talked about it. Especially distress is a big thing to pick up on. Okay. Usually start up with this program of features like coryza. Very important thing to pick up on with bronchiolitis apnea as well. Okay, so you'll see newborns with bronchiolitis just stopped breathing on you. Okay? And you should be able to after that and pick up on that. Okay. On you might hear crackles a swell. Okay, remember, apnea is a big thing to pick up on with bronchiolitis. Okay, Don't get up here as you can have the diagnosis. Okay. You'll see it all the time. You should take You should take, uh, aspirin for our speech as well. Okay, take a swab and testifier a speed. Eso again. Treatment for bronchiolitis is supportive. Okay, It's almost supportive care. So we're bringing down a antibiotics. Hydration. Very important. Okay, if they're not taking oral, be dry. MG tubes might try IV lines, nasal congestion. A case of relieve nasal congestion cause remember, babies are primarily nasal breathers. So even if you do a little bit of suction, that should be really good to improve their work of breathing. Okay. On oxygen in ventilation, as needed. Again. Remember, no evidence for antibiotics, bronchodilating bronchodilators and cortical steroids. Okay, they're not. They haven't been shown to have any improvement in symptoms and bronculitis on. These are some of the important features that would indicate admission for bronchiolitis. Okay, good. So that was bronchiolitis. Hopefully, you guys have really confident and especially distress signs and bronculitis. Let's move on to another condition. So some of us is knees, aspirin always done. It should be done in most babies. It's useful. Teo. It's really done for a lot of research purposes that's useful to know to cohort babies if they need to be isolated as well. To have nasal aspirator done in babies as your news last week should generally be done in May was a bronchiolitis um but he ended. The diagnosis is clinical okay with bronchiolitis. It's okay with that. Most you've got the great dancer. This is a okay. So discharge with all dexamethasone, Um, and safety? Nothing. So what's the diagnosis? It group where you get? Uh, Yeah, this is definitely crew cut back out. Giving you a lot of fear. Like a lot of buzz words for croup. Okay, so group the upper airway obstruction. Okay. Laryngotracheal bronchitis, fasting pictures off group are things I'd be brought barking cough, respiratory distress of gay and striper again. Any family. Um, why? Why is this patient not being admitted? What makes the well indicates that this is just a mild episode of fruit. Yeah, there's no respiratory distress. She's running around. That's it. That's important. Okay, this is it doesn't have Strider at rest, okay? If they have strider at rest, that means that you should You should admit generally. Okay, the you don't gain the strider when he's running around. Okay, so there's always indicates that this is a mild. This is my left side of group, okay? And he's generally alert and interactive, like someone said so, Yes. You don't need to admit here on down, so you can discharge with all that's medicine. Okay, so that's that's on main. Stay off. Initial natural for Group A zoo. Always a pediatric conditions. When your discharging, it's all about safety. Nothing. Okay. Even the crew, The group is just mild A group. It can be very dangerous. And so give appropriate safety net into parents. Okay? Yes. So this patient just have mild croup and doesn't require inpatient admission. Okay, Uh, can you tell me out of all of these other options, which one is the most wrong option here? I just get it. You should never do in the ent examination on patients with the croup. Okay? With patients with the Strider, Because that's you don't want to be messing about with the lions and things. You don't want to aggravate the baby. So avoid doing ent examinations and babies with, Okay? Someone said, yeah, intubated intubation is probably the most going on, so I was just trying to get out. Don't do any anti examination on babies with croup. Oh, babies. That strider in general. Um, yeah, uh, we go, This one, this is a This is obviously compassion, but it's very important in in clinically relevant question. Yeah, Well, it I will call it there. I think most of you know what the diagnosis to say it say about the probably the instructions are probably going to You could do some people. Okay, that's good. Let's call it that. So most of you've gone for a again, Uh, if you have you gone for be a swell and I That's the split I was expecting people to have. Correct answer here is be Okay, so Nebulizer Dravet Okay, so I feel most of you able to pick up that this is croup. Okay, Barking costs. Okay. Low grade fever, runny nose, uh, signs of respiratory distress. Okay. Ondas in spite of Spider all signs of group again, this is more of Ah, this is a much more severe case of a group that, uh, the one we talked about in the last six PD. OK, the signs of respiratory distress there. He's got Strider at rest is well on. He's already been given a dose of steroids. Okay, so he's already in steroids. He's already had the dose of Coreg a steroid. So we don't We're not gonna give another dose of dexamethasone. Okay, on We know this is more severe, absolute of group. So it's not just a reassurance. We need to do something again. This is a bit early for intubation again there. There's other things we can do first. So the main things we need to differentiate between is either B or C. Okay, never lies. Adrenaline or high flow oxygen again. I've told you that the patient oxygen saturations are 88%. Okay, so it's low. Um, can you have something? What is the answer? Nebulizer Drink? Why am I giving nebulizer adrenaline before high flow oxygen to dilate airways? What's the what's the general approach to the acutely unwell patient? What's the worst that a B c D? Okay, so a So we're thinking about twice that speed for breathing, right? So realize adrenaline is it was all about airway sports. That's the first step. Okay, keeping that nebulizer drilling with nebulizers This that you can give auction with it. Okay, you can drive oxygen with the nebulizers and that can help improve with the auctions actuations. Well, okay, but the key thing is it's early management first and then breathing. Okay. That's why the correct answer is being nebulized adrenaline. Okay, know, adrenaline is very, very useful. And group okay has it's very fast. Acting can improve information very quickly. So again, it is very useful in patients who are not responding to steroids, but yeah, keeping. Here's early mind from one comes first. Okay. Remember a CD, a TV set limits and the management comes first. Okay? Never, never forget that, eh? So let's talk about some signs of group. Uh, what is this X ray film indicated? Was designing was the arrow pointing towards group. Okay, we'll see actual cycle. Guess someone said it's steeple sign. Very good. Okay. Remember you. You know, going a group is a clinical diagnosis. Okay? You're not gonna take patients with croup to the X ray department to check if they have a steeple sign occasion and CVA sign. It's not very sensitive or specific. Okay? It's just something that might come up in your exams. Um, so have a listen to this. Wants this sound indicated? Yeah. Again, Barking cough. No, this is this. This is the strider. It's a high pitched sound that's a harsh strider. Sound like it's an inspired to sound again is maybe because it's hard to hear over the zoom, but said, isn't it on YouTube to do the solids again? Uh, about the sun? No, it did. You guys pick up on that? What was that sound? Yeah, Barking cough. Okay, that's the seal like description of Ah, see, Like sound. Okay. Again. Going you to listen to it. Okay. And, uh, see, like, sound. It's a barking cough. Okay, Another again. Pull a sign of croup. Okay. Again, we're gonna quickly. Okay? We've already covered most of the important stuff. So, croup, it's all about upper airway obstruction. Okay. Also known as laryngotracheal. Bronchitis. Usually caused by parent friends, uh, virus again, The key features to pick up on talking cough strider and respiratory distress. Okay, there's a lot of the key features of group. Um, clinically, you can use a score called the Wesley school, which can help Can categorize the severity of the group. But remember, it's a clinical diagnosis. Okay, Neck X ray can be useful for these people signed, but the key thing is, it's a clinical diagnosis. Okay, You're not going to use in the steeple scientist diagnose you pick it up based on features treatment, so minimal handling. Okay, don't mess about with ent examination. Don't go examining the throat around and think Let the baby stay with their parents that the be let the baby be comfortable. That's in that zone initially. Okay, on if they have moderate or severe than normal responding to, um, that's Matheson. Then you can give a nebulizer adrenaline, okay? And you can give quite a lot of medical ize drilling. The typical doses wanted 1000, and usually it's very effective in groups to relieve obstruction on. You should have a load wrestle for integration and referring to intensive care for croup. Okay, cause patients can be a very young well with you. Good extraction. It's very, for some reason now and even launched a book. Yeah, yeah. Excuse me. It might have been a bit too easy today, but it's good Diet, bones getting them right. Get down. Color that good. So mostly gone for Be correct. Answer it on. Get that is the correct answer is um mostly influenza type B, eh? So what's the diagnosis of what's there? What is this boy presented with Bergen? It's acute. Epical Texas. Okay, now this is a This is a condition. You have to. You have a solid understanding about this. Is that presentation that you can't miss it? Because, uh, as high risk of deteriorates deteriorating very, very vulnerable airway. Okay, epiglottitis patients are high risk of deteriorating, and, um, the airway being compromised. Okay, So you should have missed this presentation. So why epiglottitis those information of the big office? Uh, we'll talk about the key features, but one of the key features Article tightest. How do you remember the key features? Yeah, the three ds. Can I? Don't tell me the three least we'll come to it. We'll get to it. But yeah, This is a happy baby daughter. This is necessary. Epiglottitis to stage your drooling burger. It's on the patients. Try putting a swell is again. We talked about it. Tripoding sign of severe airway narrowing. Okay, Lauren. Sorry Away with time for us to be a respiratory distress. Okay on dot So pulling off all secretion. So remember that we call tightest patients have dysphagia. Okay, It's very painful to swallow with ethical titers. So they get pulling off all secretions. They don't want to swallow and strider because of the upper airway of structure. Okay, So this is epiglottitis on. We'll talk through the map the next step. Okay, So because the answer is him office influenza type B. So epic, Um, otitis. It's very rare these days because we have, ah, immunization schedule that protects against hepatitis. We give the same office influenza type B vaccine, which is pretty much look, which is significantly lowered. The cases of hepatitis because got dye test and unvaccinated Children is usually caused by him. Awfulest influenza. Okay, uh, because we have the vaccine now, it's usually epiglottitis we see it and a lot more whole. The patient's okay, but in unvaccinated Children, um, office is still there. Most likely caused. Um organism. Okay, so this is the same scenario. Okay, The question is just asking, what is the most appropriate next step s a half ago. It's the same. It seems to know. So you don't need to be the scenario again. It's just asking what's the most appropriate next step? Forget? Call it. Uh, good. So most of you went for B, and that is the correct answer. Okay, So, endotracheal intubation. Okay, So the key thing I want you guys to remember, remember, with epiglottitis is that babies have a very high risk out. Okay, The airways are are very high risk of deteriorating again compromised. Um, you have a very low press over intubation. Okay, with with epiglottitis, you're calling your new PSA test. You're calling ent you to send it, but trying to create a definitive airway. Okay, that's why most appropriate step is endotracheal intubation. Because epiglottitis at such a high risk off rapid deterioration. Okay, needle quicker. Thyroidectomy. So you don't need to This. So this is basically you're making a surgical airway. So if intubation fails, then the anus, If this might do, that's okay, but first up of intervention, uh, antibiotic. So you antibiotics does have a role in epic arthritis. But first, that most appropriate step is intubation. Like we said on X rays are not very useful in these conditions. Okay, you don't use X rated. Diagnose these conditions as even though What's the sign you get with that with the tightest? What is this typical sign patients have on X ray? Yeah. Thumb print sign. Very good. So you might see a number and sign by. People are tightest. Okay, on an x ray, but you know you're not going to carry these babies and epiglottitis to the X ray department. Okay? There. Too vulnerable. You call and you call in anesthetics, get them into visit, Okay? Yeah. Initial management, medical titers involved securing the airway because they're at risk off deteriorating. Let's look through this. Key bets off medical practice. Okay, So, like we said, it's a life threatening emergency. Okay? Because of risk of rapid deterioration usually caused by him. Office influenza. Okay, but now it's pretty rare because of widespread vaccination programs. Chemical feature. So you can remember the forties. Okay. Eso dysphasia drooling dysphonia. Okay, on a swell as a respiratory distress, obviously, patients get a muffled voice. Okay, because of a wheeze, secretions pulling. And then I will swallow properly, often sometimes described as a hot potato. Rice is one people patients start tripoding. Okay, because of the severe respiratory distress. And patients also have stridorous. Well, okay. Keeping with epical titers is that things happen very quickly. Okay, patients get babies, get these Children, get the symptoms very quickly. It's very acute. Onsets okay. And important not to miss terms of treatment again. Immediate early land management intubation on antibiotics are you suppose? Well, the broad spectrum antibiotics to treat the marvellous infection again on for chemo for a flax is every farmsteads also used for close contacts s so that's a big old tennis. Next question. I think we're doing okay for a time. I should hopefully finishing recent on Bravana will go to infectious diseases. Okay. And then we just focus on the common pediatric complaints. Okay. The most important ones for clinical practice. Okay, there's a lot of other ones, which I've been fluid as post election notes for you guys. You guys can have a read about, but yeah, I just did. But in terms of the actual lecture, we just focus on the most common and important conditions. I see how quick that it gets, Uh, D's. That happens. It and most of you. You and 40 Absence of bus difference. So what does he like? Your diagnosis And most most. What's the diagnosis? It are Someone's already put it. Yeah, Assisting fibrosis. Very good. So in ST a land generally as a general rule for STDs, if you see a teenager adolescent presenting with recurrent just infections, that's pretty suggestive of cystic fibrosis. Okay, cystic fibrosis. They get very sick, called up mucus, and the airways risk off very recurring chest infections, pneumonia and then get bronchiectasis, which can lead to further infections. Okay, so those dinosaurs is cystic fibrosis again. This is also suggested by the failure to thrive. Okay, so I did weight below the 10th percentile. The diesel polyps, also very common with cystic fibrosis and also bulky foul smelling stools, are hard to flush. That this is describing theater area again, again, sign of pancreatic insufficiency, which is very common, insisting by process. So I didn't want to make it question too easy. So questions asking, what's the additional feature? Can the patient have? So what? Which of these can be seen insisted by bruises? And the answer is absence of vast difference. Okay, so most boys with most men with cystic fibrosis are infanta. Okay, So because they develop absence of bus difference for some reason Yeah, that's why the correct answer is he, uh, dermatitis have fatty formers. Uh, What's what? Which What? What diagnosis has that as a complication? Yes. Select diseases. Moving Talked about this on this session, but, um yeah, see, like disease doesn't explain on the chest infections or the nasal polyps. Boston, that area. Okay, um Dextrocardia Ah, what would dextrocardia indicates? Very good. Contacting a syndrome because I just introductory one of my favorite conditions. So cartilaginous syndrome I have included as post lecture notes, but cartilaginous syndrome patients can get, uh, this complication known as a scientist versus where that organs shift to the other side of the body. Okay. And so the heart's on the other side. That other ovary bogans can be under decide, and they can get my displaced heart sounds and displaced a pack speech and things on. But this isn't This isn't a contact us. And, um, this is a cystic fibrosis between C deficiency is very rare. Occasion retinitis pigmentosa. I just added, It is a random option. Okay, so you can see there's a d. So it's quickly talk about the key features off CF. Okay, so it's a multi zone recessive disorder contrast by a defect in the CFTR gene. Okay, which least you thick, dehydrated secretions. Okay. It's a multi system disorder. Okay. Affects multiple different organ systems, but primarily primarily with clinically. We were thinking about the pulmonary involvement and the GI I involvement. Okay, as a beaches, recurrent chest infections. Okay. In terms of the actual bugs in Children, it's mainly staph aureus and, um, office and all the people that think about pseudomonas. Okay, so Pseudomonas aeruginosa, uh, patients can get bronchiectasis because of progressive every dietician needing to, um from getting cysts. And also you get nasal polyps because of point sinusitis as well. Moving talked about meconium my list and his lecture. So most patients with meconium Eilis where? Where they failed to pass the first stool within the 1st 40 hours of life. Um, that's usually caused by a cystic fibrosis game. Meconium Eilis on moving talk about a lot of the presentation that on medications can also get pancreatic insufficiency with CF, which can lead to malabsorption between lead to steatorrhea family to drive and diabetes on. There's other features as well diagnosis. So in the UK, we have a very good screening program for CF s. So you have the new one screening program there. Gilbert. Blood tests were were detecting this, uh, trypsin protein which is used to pick up CF uh, symptomatic patients. We can use the sweat chloride test, which is a confirmation test, and the value we use is greater than 60 to diagnose the CF. Uh, genetic testing can also be done in a certain cases as well. Okay, Or once you've confirmed, if the positive sweat chloride test, then you can refer them for genetic testing. Treatment of CF. It's very multi fasted. Okay, there's a lot of different things going on with CF patients. Okay, you're finding doctors who just specialize in treating CF. Okay, because there's a lot of different aspects to careful cystic fibrosis patients and some of the pulmonary disease. Big things are chest physio. You can use things. I'm eucalyptus to try and break up the thick mucus Antibiotics can be used for flare ups. Exacerbations of CF, then for prophylaxis. Okay, um, and in terms of the pancreatic insufficiency we can use, we can replace pancreatic enzymes using crayon on if they get diabetes. As as because of that, we can use insulin and this other things as well. Obviously there's a big interest in the use off CFTR modulating drugs. Okay, there's a lot of talk about these drugs for use in CF. Okay, things like either CAFTA, um, a lot of politics to do with those drugs as well, Which and so a lot of you're aware of. But he's a very exciting drugs. Fourth year treatment. Okay, uh, we have two more SPS. And, uh, there were I mean, this is a question about aspirin. Phelan's This is, uh I did. This is I personally wrote this question because, uh, the DTs got the lines, and the nice guidelines are quite different. Okay, but this question, they overlap in both. So it doesn't matter if you're going by pts guidelines or by nice guidelines. The answer Still same. You know, Uh, yeah, most of you gotta get see? Inhaled montelukast. Okay, So you got a asthmatic patient here who has been established on, uh, inhaled corticosteroid therapies. Are you on? This was already on back on its own, and he's taking salbutamol as a last medication should, So it's not. You need to escalate care from it from this current management on the most appropriate next step is, um, inhales. Want to look at stuff? It's a L T R e. Okay. So look trying receptor antagonist. Okay. We'll talk through the guideline. Mind if it's okay, but, uh, it seems to step up after I see yes, uh, for Children over the age of five. Going to beat? Yes. You can either use a L T r a or a lab. Okay, but I intentionally didn't include any option for ah lover. Okay, so the only a progress appropriate option care was L t r a m. So that's why the correct answer is inhaled montelukast. Okay, because I'm going to be just guidelines first. I don't therapy after I CS would be either a l t r a or a lover. Okay, uh, I don't do the guidelines, so Oh, sorry. Yeah, Monty, I think I, uh yeah, montelukast you get orally following apologize for that. Yeah. One of you guys know Anyhow, it's always be, uh, yet you ever change that when I send the slides for yet. So this is basically a table summarizing the PTSD islands. Okay, if I ask your management's again, I really emphasizing the guidelines here because the nice guy lines are are quite difference. Okay, So I'd recommend just finding out whatever your medical school exams test you on. Whether it's more peaches are lines or nice guideline, the ones have some, Right. There are the Pts guidelines. Have a read off the actual step up therapy it or really want to emphasize. Is that all Children? Children for us? A management. Should you using a metered dose inhaler, pressurized meter dose inhaler with a spacer device. Okay, so all Children should be using a spacer devices for that inhaler therapy because that's gonna significant. Improve that delivery off delivery off the therapy and improved that compliance as well. Okay, it's much easier to use a spacer at in younger patients. You should. If they're not able to create a good seal off the actual space of device, you should use a facemask A. Well, if they're able to create a good seal around the spacer, then you can use a mouthpiece. Okay, But again, keep thing is that you should use a spacer device. Okay, that someone's ask what's the main difference between nice and be chest? So it's quite different. Okay, with nice guideline. As they talk about using six week trial off, I see US therapy initially and then assessing So assessing that response for Children eight over the age of five day prefer to use labor okay over L T r A. Because labs are more effective. But er is arm or cheaper. Okay, so ltro is technically a more cost effective option in Children who respond. But Lava's evidence shows our lab is a more more effective on. I've really summarize the guidelines. Say, if you could really go into a lot more detail talking about when you should combine inhalers into multiple therapies and things I'd recommend just having a read off the nice guy life. That's just a pure summary. Okay, which I think is enough to know for your exams in terms of the Pts phone lines. But I have a read off the guidelines. Here s that's chronic asthma management. And now could you want to go over acute asthma? Okay, Now, a lot of these things overlap with adults, Okay? In terms of the severity of asthma again in terms of how we classify the severity of an acute asthma exacerbation side, the moderate severe life threatening or near fatal. Okay, as I have a read of body speech is I'm sure you guys are aware of things like a silent chest and exhaustion and confusion is all very worrying. signs in a spastic patient. But the things you really worried about is if the prostate cancer off common doubts and he's going up okay, if there so two is going up, that's a very worrying sign. An asthma okay, means that they're not compensating well in terms of management off acute asthma. So if it's just moderate, then you can Hopefully, babies will respond to just using a suburb using a spacer device, and you get a little prednisolone. Um, but if it's most of the year, then you want to be using a high flow oxygen evening for SAT about over 94% on. You also want to be using nebulizers. Okay, So back to back nebulizers drive Oxford with in with them. That's the mainstay for severe asthma. Okay, um, also if that know, responding, then you can consider things like a petroleum like he's himself. Eight's okay, But at this stage would be referring them to intensive care on. They might need to use intravenous therapy. PSAs Well, last question for me, and then I'll go to her. But, uh, I know it's been about a content heavy session from my side, but we're finished with this question. Okay, I think I have a drink for most of you with this one. Yes, sir. Ago. But I'll tell you right now, a lot. Most of you getting this one wrong. You can call it that. Eso? Yes. So most of you have gone for B. Uh, but the girls can say is actually see? Okay, it's a nasal CPAP. Okay, we'll talk to you. Why? It's an important learning points. Okay, so let's talk to you. Why? So we got a baby? I was going premature. Okay, on basically, these babies got features off units of respiratory distress syndrome. Okay, so born premature. Big risk factor on units of respiratory distress in room on. It's got grunting to keep yourself course of attractions sinosis. Okay. And the key X ray finding for you need to respect the spirit of distress syndrome is the few surround last just densities. Okay, these are all features on units of respiratory distress on, but the question is basically asking which of the following is the most improvement next step. So what's happening with the needs of respiratory distress is that does deficiency and surfactants on. If you guys remember from physiology. Surfactant is really important to reduce surface tension to prevent alveola from collapsing. Okay, so this baby is deficient in surfactant, which is increasing the risk off all the other collapse and atelectasis atelectasis on. So that's what's happening in units of respiratory distress. They have a deficiency off the Factive. So can you guys tell me wise option B? Not the right. Answer him. Why? Why am I not giving intravenous surfactants? How how you How do you give some Bactine two babies? Yeah, you give it. You know, basically, you don't give it IV, okay? You give it through an endotracheal tube. Okay? That's how you give until jenesse artificial. Subtracting two babies. It's not true. And it is not through an IV. Okay, you give it through and you interviewed and then you give it directly onto the lines. Okay? That's the key learning point that you don't give. It's a fact in IV and also the main, the main stay of mental history off supporting ventilation for mean it's expected. Distress is nasal cpap. Okay, because basically nasal CPAP provides peak. Okay, So, people, you guys know your ventilation, physiology and people is basically that end expired to print pressure that basically helped prevent alveolar collapse again, which is very important in units of respiratory distress, because, um, they have a lot like of surfactant, so that will be early are predisposed to collapsing. Okay, so that's why CPAP is the most important. Um, stay of cap. Okay. Along with giving surfactants. Okay. But again, remember, it's a fact, and you give it with their to an end of trickle juke. Okay, if there's a corticosteroid so you don't give corticosteroids to the baby, you give it to that, you can give it to the mother. Okay? If you if you if you're if the mother is expected to deliver Premature preterm, okay. And the baby's expected to be delivered prematurely. And you can give the mother steroids because steroids have been shown to increase the fact in production. Okay, Which could be which would be useful for the baby, Um, intubation. So it's been to relieve intubation again. And, uh, so I got sick. So most operate appropriate option. Here is nasal cpap so quickly on the units of respiratory distress syndrome. So it's all about a lack of stuff accident, okay. And I talked to the physiology here. Essentially alveolar gonna collapse, which can really too high pox here and hypercapnia. Okay, risk factors. So keep this fungus prematurity. Okay, but maternal diabetes as patients who've had a cesarean perinasal situations off urinate socks fit CIA are all notable risk factors as well. But the big thing I want you to remember is prematurity because shortly after, bit okay. And the key features are experience. You distress, but don't a definite out. Hopefully, you guys are really confident and knowing signs of respiratory distress test at the end of this on but ky chest actually finding are grown glass infiltrates. Okay, it is the treatment. So nasal CPAP is the mainstay of mental edge off noninvasive ventilation. But this is really important. Okay, remember this Another big thing with patients who have any initial speech distress. You want to be very careful with giving a lot of oxygen to these babies because the prolonged auction that would be is toxic. Okay, there's a lot of complications. Okay. Babies can get blind. Okay? The rest of your prematurity as a very it's a known complication of giving too much oxygen. Patients completed so intraventricular hemorrhage. Patients can get heart defects like a eight and doctors Ontario says, because usually the doctors arteriosus closes. When? When there's a drop in option. Okay, after bit. But, uh, doctor tears will be maintained open. Okay. So you can get patients started. Really? Says on the big complication or prolonged auction. Darby is a Bronco pulmonary dysplasia. Okay, so chronic lung damage problem damage off the really small airways again. And this is particularly important because this can be opponents. Okay, So you really want to be careful with giving too much oxygen? Two babies, um, in terms of other other things. So remember, we give surfactants, but we give it to and end of trickle tube, and steroids can be given to the mother prior to both. Okay, To increase, Um, some Bactine production. So good. Uh oh, yeah. This is a this a lot special. Actually, I just threw this question in there because it's, uh we're talking about pediatrics. So I thought I'd throw in this ethics question to you guys quickly and then I'll 100 over to rebound. Okay, This isn't really related to pee a trick pulmonology. And I think this is just a ethics question. That's very topical, but pediatrics. Okay, but which I thought would be important to address. That's part of the pediatric. See me? So content we we were putting up. Yeah, I get, um, uncle, that that just see most of you will, uh, under the world those. Yet most of you will have done things like, um, um, either things be and be confident with approaching these kind of scenarios, but yeah, because his be okay. This is a medical question. Probably something that might come up in your ST 80 situational judgment type tests that you'll have to do in later years of medical school. But yet good answer here is be so give a lot of blood products as needed and explain situation dependent so quickly. We got a child here who is involved in a major road accident. Okay, She's lost a lot of blood. Okay, She's risk off on a magic shock again. Um, how she's got hemorrhagic saw Shaq. Okay, so basically, she needs blood products to lives. Okay, So the after ghost concerned it is Do we give blood products? And the answer is yes. Okay. The key thing here is that parents cannot withhold lifesaving treatment from Children, even for religious reasons. Okay, this is a five year old girl, okay? She's not old enough. Even if he even if he was conscious, he's not old enough to consent to not refuse treatments. Okay, so and parents for not with holes of life saving food. Okay, so you just you give the blood products, okay? You don't need to even contact legal support or anything. It's well established ethical rule. Okay, Has come out with whole life 17 when you give blood products as needed. And then you explain the situation to the parents. Okay. Um, yeah. This is just a quick acting scenario I wanted, but I just threw in here if you guys are very confident and approaching this, but yeah, that's it for me today. A handout to read about. I got some post lecture notes for you guys. You got some notes on foreign body aspiration notes on pediatric choking notes on preschool reason. Okay, so differentiating bottle and you squeeze on asthma. Louise. Uh, primary surgery dyskinesia. Okay, so we talked about the dextrocardia and the contact in a syndrome, uh, some notes on whooping cough. Okay. The testes infection on a little cheat table of comparing the other cause is off the spirit of distress and Children, hopefully will be very useful. So 100 over there. Avandia. You're slightly over. But yeah. Go to you about Thanks, guys. So, uh, be in the shop. Cool. Um, yeah. The feedback for Ms already been shared. Do you guys want a minute break? Before we stopped Way are gonna be going through pediatrics, infectious disease as well as a bit of pediatric dermatology. That is really, really how you made it, For example? Um, cool. Shall we started eight in three minutes, then? Yeah, Yeah. So we will give it to three minute break, and then we'll, uh we'll start back up. If you guys have any questions in the meantime about my talk having to take them on that. Okay, rebound will take of it. I'm just while you guys are arresting just a heads up. There are gonna be pictures in this in this question's a swell and everything is referenced. So I mean, the pictures really, really help with aiding in terms of learning. So that's why we tried to put it in if if anyone has any. Any issues, please, to let us know front romance. Using your finishing time for apprentices. I don't know what's apprentice when you want your friend this now? Um, yeah. Many people have been asking me our local university with the base. It on BDs are nice guidelines, as far as I've seen, they usually based upon nice guidelines. I heard we had this conversation myself. A nice yesterday Also, which is why he had, like that. The nice guidelines it would be. This is this is according to my experience, I can't say for sure, but, um, yeah, tends to be nice guidelines. Yeah, because I think probably unlikely that they test you If there's different guidelines about this in your medical school, on down all honesty that the first three steps are, um, the same in both guidelines. First 2 to 3 steps up. Same in both eyes and below five. Frustrated about five stents, first two. So, um, I mean, I'm not sure. I've only encountered once when they asked these six line in adult management of asthma. Uh, so adult management, they just for the nice guidelines. That's the only, uh, scenario that I've seen for you of Doryx Mine's been used. Beach. Yes, remember. Pts is used for pneumothorax. So, you know, learn that algorithm. If it's greater than two centimeter, less than two centimeters. What you should do? Cool. Are we ready to start? Is it cool? All right, let's go through a bit of infectious disease. Um, some questions are tough. Some questions are easy, but I'm sure you're You're not smart people. You get the question straight. So let's start up with the first question Now, um, launched the pool. So So this is a new need who seems to be prematurely born four hours ago, and it's my specs. A temperature? Um, yeah. So there are a few risk factors that will go through, but let's see what we pulse saying. Yeah, cool. Let's ended up. A majority of you guys have actually got the right answer here. And the right answer here is a band pen. And gentlemen, gentlemen, insulin and gentlemen, I said now let's try to identify what exactly is going on in this in this scenario. So the baby aspiring the temperature, and immediately you're thinking a premature baby speaking temperature. You take thinking of neonatal sepsis? No, this is reinforced by the fact that there is, uh, a ruptured membrane has lasted for 24 hours. Now, a ruptured membrane that's lasting 24 hours is categorized as a prolonged rupture. Remember, anything about 18 hours is a productive member. Imagine that the membrane surrounding the baby has been ruptured and baby just sitting still. Now this because of the vaginal, conventional bacteria has a higher risk off the baby. Contracting diseases are infections, basically because off it just being there and progressing too quickly. That is further reinforced by the fact that the baby seems irritable as well. This is It's not feeling well with regular bombing thing. So a few conditions in this case that you're thinking about is stuff like sepsis, meningitis, last neck, uh, Nick that the baby is experiencing. But it doesn't seem to have any signs off because there's no bowel distension. There's no John Doe's. There's no science off too much off any, uh, gastrointestinal disease, especially with passing off meconium, passing off bloody meconium and things like that. So we're we're suspecting sepsis here, and the main way to understand and treat sepsis or any infection infection. For that matter of fact, it's understanding why the antibody actually treats that particular condition. Now we have this two antibiotics pending help insulin as well as gentamicin. Bendel penicillin is really, really good in covering gram positive. A bit of a gram negative, positive mainly and gentamicin covers A bit of grandpa did the milligram negative. It's well, now the mean organisms in this case is be. And this is a group B strep on. This is a gram positive organism. Now, if you if you look at all the organisms that are basically that a baby can basically get in a scenario which is Subsys it it mainly revolver on a gram, positive and gram negative bacteria. So we're trying to identify what antibodies still to suggest that to go to choose you tend to cover positive and negative. Now, if it was neck, do you want to add metronidazole? Because neck could have stuff like C diff, which isn't really likely. But you want to cover anaerobic bacteria so and metronidazole covers anaerobic bacteria very well. If this baby was allergic to penicillin, you go for careful attacks of me because it it's a third generation careful aspirin and it it's more important. And it's very good name in eliminating this sort of infections. But your first would be a gram positive and gram negative cover Just been on cholesterol and and gentamicin. No, I'm not really gonna go through the exact mechanism of sepsis, But this is sort of the path of ideology that I like to think about when thinking about what sets substance. And this happens both adults as well as needs as far as Children. So the macrophage is They release all these factors in the loop and enough alpha nitric oxide, which basically eyelids. It increases the community, causing fluids to shift out the fluid shifting out causes the deposition firing all across the board. It finally also because it wants to repair this sort of fluid moving out, which is one of the factors that causes the icy and disseminated intravascular quite lip coagulopathy and the tissue, because it's filled with a Dema and all this kind of debris is type of high purpose refused, and that's where the lactate realizes, because off this anaerobic respiration that the muscles undergo on. So that's why I mean monitor we do the Subsys six to identify for elected and all the other antibiotics, oxygen and stuff. I'm sure you guys know deception six. So you know it'll subsists. What are the silent and symptoms? So it differs from a normal human anomalies man or woman on in unit Because units experience are not able to express themselves that they can say, Oh, I'm feeling feverish. All they do is they cry. They have poor feeding, They have a change in behavior and one ti what that you need You need to make sure that, you know, is basically the word irritable. Now, if a baby is irritable, you're already suspecting the injectable sepsis so they could have a floppy tone and sign Arctic off mottled appearance. And what a mottled appearance is. Basically, this is sort of roundish lesions that you see all over the skin. This is a model appearance. As an issue mentioned, they could be in respiratory distress because of the edema building up in their levels and they could have seizures. So because of the high temperature now, this could be invited and infantile spasms. If the fentanyl seizures, uh, it could be at the end of day. It could be not life threatening, but you'd want to definitely treat in your little steps Sepsis. Now, if we go through the pathogens that could possibly cause your little Subsys Group B strep grand, positive, equal and gram negative road stuff with the MS is grand Positive Pseudomonas gram negative collapse telegram negative. And you're about back the grand positive caucus. So you're balancing between gram positive and gram negative. So your bones are penicillin and gentamicin is going to do the job When you're looking epidemiologically be at the causation bacteria. Now there are a few risk factors from noon it'll sepsis. And in this question, I put two risk factors. One is the, uh, pretty much a rupture of memory of absurd, prolonged rupture of membrane, which is over 18 hours. This this lady had a ruptured membrane of 24 hours as well as prematurity. Just because the lungs haven't been developed, the immune system hasn't been developed. The EKG hasn't been transferred completely credible. Center to the child of the child is at high risk off the sort of infections. Now the race temperature in the mother could mean a condition called chorioamnionitis, and this puts the baby at a risk factor for noon. It'll sepsis. What exactly is Korea and united Chorioamnionitis is the infection off the Korean, which is the amniotic fluid in the baby is encompassed in Now. This happens usually when there's a prolonged rupture of memory, because again, the bacteria has a longer time to colonize any in fact. And it's usually the appearance that you might see is a very, very false smelling, discharged discharge with very thin running fluid. And when you are when they're sort of seeing the clinical picture off prolonged rupture of memory plus this sort of race temperature, you're already thinking off this new little subsets. That could possibly happen because the immune it could get infected as well. So the management for neonatal sepsis is, as you do with any any normal, normal human being. Also adult also, which is deceptive. Six oxygen fluids. Antibiotics Give three. Take three lactate blood cultures and imagine your urine output. Now anyone knows how you manage your urine output in unit, you put in the chapped Well, we're not. This is possible weight. Yes, so when that you usually see what happens in a slightly all the baby rather than in unit, because the needle it yes, it could pass a meconium and stuff, but yes, you're right. You want to catheterize the baby as horrific that as it sounds, this is the perfect me to imagine and measure the urine open. And this is what you'd be trying to do. Uh uh. You want to rule out UTI so that it could cause this sort of new little sepsis? Cool. So there's anyone know what, exactly? I'm trying to get across here with this picture, right? Correct. So this is a non lunching rash. Now, what exactly is a non blanching rush? A nonblanching rash is when the capital the small bladder is in your skin has basically leaked out a certain fluid that it's it's tissue fluid that it's leaking out. But now this has ruptured as well, causing a small bleed. I underneath the skin. Now this bleed. As long as you push it, you're not able to sort of move it around because it's there, it's it's bled out, and it's not really going anywhere. And that's what it nonblanching rash. Uh, it's basically And what do you think it. But when you when you see a not blanching rash, when you do the glass test or you can just pinch at the site is off the rash and to see whether it moves a potential changes. Color is meningea focal septicemia. Now this is a complication of services itself, and there are certain procedures. It's a similar management, But the reason why I put number puncture in big is that you want to consider that clinical picture before thinking about doing a lumbar puncture. Now, if you're if you're observing in this start off rashes and stuff, it's patent morning for meningococcal septicemia. So you want to just start the treatment rather than doing a lumbar puncture. If you're unsure off the origin off the meningitis, or if you're unsure of the origin of except Subsys you to do a blood test for substance, you do a lumbar puncture for meningitis. But this is pat anymore, so other manager meningitis causes him off less influence. It be our pneumococcal meningitis, which wouldn't really produce this stuff. A picture you think about doing a lumbar puncture. You don't want to do it too quickly in units because you could really enjoyed the spine. Now, one thing that I wanted to highlight is that the elected and blood cultures you can't really you can really gain to Could've intravenous access with units because their their veins are not really being steam. So you do a capillary blood. Guess a capillary blood? Yes, is actually done in the on the top wages. Uh uh, the the new lady and you push the blood of up on. Although this is prone to a higher amount of human license and stuff, it's the best that you can get with your unit because you can't really find a vein did in the unit and and try to get blood from that. So this is the sort of management that you try to go through. Cool Can. We launched the pool again. This is a slightly difficult question. Um, but and trying to convey an important point, uh, by by giving this this this question, quite a few of you are struggling on what exactly? Select that there is a three weeks. I know. So, um yeah, that's excellent. Putting be access. You Okay? Let's Let's end the pole there. Now it's a three. It's a very close between B, c and D. But this condition is not really talked about too much and not really understood too much by medical students and generally generally clinicians itself. So that's why I thought that it might be good to go over it. Help understand what exactly it is. The right answer here is actually systemic. Juvenile diabetic arthritis. The reason why this is the answer is because they're swinging fevers and muscle being muscle pain, stringing fevers and sort of joint pain. All these kind of a whole list of symptoms Problem point you do. It's a system in general. Idiopathic arthritis. Now another. Another feature that is really, really powerful monitor is the sort of rash this is called a salmon pink rash. And it is. It is something that happens in a systemic generally Oh, you're having arthritis and we'll just go through it in a in a minute, what exactly it is, But this system, in general dramatic right? This is one of the rare condition. The most common juvenile, depending arthritis, is actually only go articular, a juvenile idiopathic after practice. But this salmon think rashes pathognomonic for the system it juvenile diabetic arthritis and all the other conditions we will and they go through in the next coming sites. But I just wanted to point out an important, important learning point here. So there are different kinds of juvenile diabetic arthritis and and the Sinus related, which is seronegative but actually be be 27 associative. Majority of it is actually a B 27 hours associate it. What this basically means is there's no specific antibody that could attack it, but there are genes that could contribute towards it. Now there's a systemic juvenile diabetic Arthritis, which presents with it's called Still's disease, presented a salmon pink rash. The seventh rash actually generally tends to move around the body so it doesn't stay in one place. It moves around over weeks. You know this weight loss, swollen lymph nodes, joint and muscle pain in a race CRP And yes, sir. Now there's a polyarticular, and probably articular is important concept to remember because it's applicable for even a rheumatoid arthritis. Actually, juvenile idiopathic after activities, was formerly called juvenile rheumatoid rheumatoid arthritis. So a polyarticular the definition of the articular is greater than five joints, and it generally you generally is symmetrical with mild fever and reduces growth and anemia, whereas all legal articular is four joints or less. Now, Oligoarticular, I mentioned, is the most common juvenile about the arthritis, and I've seen, I think, one patient in my in my pediatric block, who Kim presented with this. It's not as uncommon as you do. You think it is usually presents in the female demographic. More than a million mammographic hey, disassociated with anterior you uveitis and and the nuclear antibodies positive and finally, psoriatic arthritis. You see that Class C changes of psoriasis on the flexor surfaces it in symmetrical. It's a poly arthritis. Well, it's you're negative. And as I mentioned, your T psoriasis and then flexor surfaces, it's very extensive surfaces colleges. So the treatment for this juvenile diabetic arthritis would be considered for pain relief. D mods. The many mothers been used in this day and age is methotrexate for this condition, and finally, if it's really, really severe, you would think of using intra-articular or intramascular steroids. The reason why you don't really use direct with Children is because they have high risk of osteoporosis and stunted growth that that, uh, a side effects of steroids that you'd see in giving, giving a young Children cool. So let's move on to the next question. Now give it a few more seconds for you guys dance toe. Attempting these questions really help because even when I'm in bed and it's be a sessions, I tried to attend the question. So even if I get a little wrong, I remember why I get it wrong. All right, let's end the boulder. Yeah, majority of you guys have actually got in the question, right? And the right answer is colors like his disease. Now let's try to dissect this question and understand what exactly is going on. So jackets presenting with Heidemann Bridges that's lasting for six days on does a very famous maculopapular rash one. This, um, maculopapular exactly mean can someone put in a chip put in a check what is immaculate me. Right. Okay, so yeah, macaroni. It's, um maculopapular Media Macular. Um, it's flat and popular means raced, so it's a flat and raised lesion across the skin, and this is what you'd see in color Sarkies disease. It's it's it's not specific to cause of his disease, but the other sort of features also contribute to come back. It's This is because his disease you generally have a very, very high fever, which lasts more than six days, and this can be contrast. Do another condition that we'll talk about later in the presentation. Kawasaki disease. It tends to have this sort of maculopapular rash. You get a strawberry on appearance. Acela's cracked lips. Um, this other SoCal appearance is that you get with others. Okay, Disease? No. Can anyone named me? What exactly this. This complication of Cozaar key diseases in the picture? Yeah, absolutely right. Just written here. So this is called these Commission. This information is basically the peeling off your skin at the end of your tips. So at the end of your fingertips, at the end of your toes, they stop, start peeling, peeling nature peers. And this usually happens in the first after the first or second week off the disease itself. Usually not when the high temperatures President this decommission is not sinister. So it generally book on itself itself resolving on. So you don't really have to do too much to to treat the discrimination. But however, for Kawasaki disease itself, you're thinking off sinister causes that could cause death. And so what you're treating it with is three. Usually the one medical usually tells us it's I don't aspirin. But the first line and the most effective line is actually, um is actually, uh, IV I g I v I g is really, really useful in terms of Kawasaki disease. Now there are a few features that I just talked about. You notice the strawberry tongue, crack lips, cervical lymphadenopathy? No, There is an important point of not with the cervical lymphadenopathy. It's usually in the cervical region, but it's usually unilateral. It's not bilateral. So you notice a unilateral cervical lymphadenopathy. You notice this wide erythematous rash this convention of pumps it does in the progression of the disease. Not immediately during the stock, about one to do with these Internet a disease and you noticed bilateral conjunctivitis as seen by bilateral red eyes and if even assisting greater than five days disease, what they're thinking about as I mentioned in acute situation, want to do a week's lymphadenopathy People rush discrimination about 2 to 4 weeks, and the Conradt Contin convulsant feature, which is regressing face when everything starts becoming normal But then you still want to treat with this high dose aspirin and IBIG. Now this is one of the exceptions that you give to Children your extensions where you give high dose aspirin two Children because off the complication of race disease way we talk about race disease. But does anyone know exactly what raised this is a recent illness? Yes, it is from aspirin, but what exactly is it? Yes, yeah, so that's That's the one I was looking for. So it's It's actually a group of features, but mainly the final future. Would it would be hepatic and careful. Ah, pretty. There's stuff like, uh, brain involvement is that liver involvement on there's this loans off this type of complications. It's multi system complication that that could happen. And once you stop when she starts seeing this, you immediately stop the aspirin. That's the the main show. Any new trips start treating slowly, start treating the symptoms we throw around breasts, race in rub as a complication for in Children for getting high dose aspirin. But it's good. Understand what exactly? This Jesus and course? One of the main complications around the two week, three week mark is coronary artery aneurysms, whether it's just weakness in the coronary artery that could rupture and cause heart attacks. So you want to monitor this by a transplant stressing ultrasound, You wouldn't want to go straight off to the gold standard, which is a CT angiography because of the exposure of radiation and Children. Cool. So there's another condition called you know, option pop urine, and as it stays in the name, it's the sort of purpuric rashes that come upon across your body. But your rashes are small, tiny vessel bleeds that appear on that are really pinpoint. So with, you know, popular. The classic question is, you notice a that ended in the childhood, the the child has got in the sort of papyrus rashes. And in adult, you know, this hematuria are hematuria and protein urea. What exactly is the is the sort of course for this, and the right answer would be I g n a property. And the reason why this happens is because the origin of the national but your as well as a Jennifer upper gi, is this idea vasculitis that's causing it. It is a complication that could happen in the future for, you know, people who have it. Just be. Now you notice purpuric rashes, joint joint pain after involvement, renal involvement. A Cialis, Uh, as I mentioned microscopic hematuria and protein urea. It's caused by this IGA vasculitis, and, uh, the diagnosis is usually it's not really required for us to know, but it's usually by this Euler window or pressed criteria. It's more used in the US, but you can. You can see it being used. It's kind of a clinical diagnosis that you see you be able to tell that this is his speak, and but you want to do idea histology to see energy deposit, especially that killed me. But this is more of a clinical diagnosis, and steroids are not usually used in the management because there therapeutic benefits have been really questioned. But since they're the negative effects, as I mentioned earlier for Children, so you just have supported management and you monitor their renal so renal test so that they have not developing this g of ask you like this are gene a property by doing this urine, dipstick and blood program a monetary and this is what this sort of pop your ears rashes. Look, as you can see, the pinpoint just small bleeds all across the body, Uh, most like most mostly your seed on the child's bottoms. All right, let's go on to the next question we have, I think, 3 to 4 more questions left, and then we'll be done. So seven year old Daniel is coming to the GP complaining of tightness and decreased food intake and a full blood contest on. And this is what it shows. What do you think is the right answer? Okay. All right. Let's stop it there. So this majority of you have got any right, and you're absolutely right in saying it's farmers being 19. Now, this is a picture where you see him, um, blowing blow. Been being low platelet being low white blood cells being a relatively low and ready killer size being normal. So let's let's try to explain what exactly is going on here now? Probably Virus B 19, also known. Also known to cause the side of slapped cheek appearance that you see on on babies. It can cause a sequestrian complication called a plastic crisis. Now a a plastic crisis. This is when everything seems to be low. You would be wondering why the particular sites are normal in this condition. But with a hemoglobin that low, the reticulocytes need to be raised because new red blood cells need to be constantly being produced to be supplementing the low hemoglobin. And so that is why this is still a plastic crisis with normal range particular sex. You need to see the whole picture before deciding that whether it's a plastic crisis on, uh, because generally particular sites would be raised to compensate for the hemoglobin. So, um, in the past, the different kind of rashes have been really, really community label for us. That's the 1st, 2nd, full 5th and 6th disease. Um, and we'll be going through every single one to see what the science symptoms and features are. Um, first being measles, college fever, rubella, dukes, disease probably be 19 and Brazil a infant. Um, so let's start with measles. As I mentioned way, look at a few pictures as well to understand what exactly is going on in this condition. Measles caused by measles virus. It's usually the symptoms usually tend to occur about 10 to 12 days after exposure. You notice fever Kreisel symptoms and conjunctivitis the initial stage. So the prodrome a stage you noticed this sort of complex spot in the back of mucosa. Public spots are basically this sort of white spots that you know this in the in the mouth region and then the actual infection itself. You have this fever, people, high fever, Kreisel symptoms, and you notice a rash starting from the back of the ears and moving all the way down. And that's really, really important to remember, because there's another condition where the rash start in the neck and move still. So this rash you notice it, starting at the back of the years and moving down. And remember for an asking, You want to say that it is a notifiable disease and you notify the local local, uh, local infectious disease committee. Cool. So let's move on to scholar fever. And, uh, scarlet fever is caused by a group. A strep group. A strep strep Biogenesis is a very, very little little, but it causes lot of conditions which will cover in the in the next few slides. But yeah, so it's called a fever. You know this this red are playing. Think a blotchy macular rash and the key word that you need to know if in your eyes being is this rough stance and people texture, you know, this fever lethargy. So through tonsillitis, because patchiness is one of the causes of tonsillitis, so it could be a sequel. E you notice this strawberry that junk, which you did see in a Kawasaki is disease as well, and you'd see cervical lymphadenopathy. Now, as long as you see a group a strep, the antibiotics that you think about immediately is fine. Oxymetholone insulin, also known as spendy still, and we and you give this for 10 days. So group A strep, you know, meet up in missile in group B strep benzylpenicillin. And this is the type of, uh, antibiotics. This is how you do the association's This is how you associate different bacteria with different antibiotics. It is also a notifiable disease, and there's a 24 hour school exclusion. I've included all the school exclusions at the end in the post election. Not so. If you'd like to take a look, I want to Welcome to this is the sort of strawberry time that you'll get, and this is the sand paper type of rash Did you see with scarlet fever? So we have doctor but first disease and second disease. So let's move on to third disease and forth disease. That disease is rubella. It's usually spread by respiratory droplets and uta erythematous macular rash. Around three days, you notice, uh, enlarged lymph notes, and it is a notifiable disease. There are few recommendations such as thrombocytopenia and careful itis and even one of the recommendations that you'd see it which which has a mother to child transmission, is this deafness, blindness and congenital heart. The's old categorized as congenital rubella central. This is the type of rash that you'd see here. Um, it is a everything went every damn. It is macular rash, that beauty in rubella. Now it's not really seen in this day, and it just because off the MMR vaccines, but in people who are unvaccinated, I don't believe in the vaccination program. Just remember to keep this as your differential. The next disease is a relatively simple disease to remember. It's called the fourth Disease, but it they just said that similar to rebel, Uh, but no one really knows what's happening. That's no specific organism that could find that. That's not a specific explanation that that you could find. So I guess it's more off any. Any rash that doesn't fall in the category off all the disease is that you've seen so far it and to classify and reduce disease with similar symptoms to rubella. Now the 5th and 6th disease is the one that medical usually likes to test. UH, mostly so probably virus B 19. You noticed this sort of slapped cheek appearance. I don't know. In this case, maybe ask is really suspect, Um, any abuse or anything, but it is always a good thing to have in the back of your mind. But if you if they're presenting with mild fever, cries er, as well as the sort of slapped cheek appearance you're thinking off parvovirus B 19, the toxin that's causing. This year, as I mentioned, you noticed this diffuse red rash, but 2 to 5 days after exposure, and this is ridiculous rash on the body that appears a few days later off this slapstick fresh. One of the complications, as we saw in this in the question is, did plastic anemia on disses when everything is just decreased. And this sort of a mild suppression that you a mile a suppressive picture that you'd see where everything is low and a few complications Is fetal that mother to child cancellation and give her like this or meningitis Now, roseola. In fact, um, if I've been pronouncing that that right is the six disease and the final one off the first of six Siris. It is caused by a jittery human herpes virus six. But in rare cases, it can be caused by human herpes are seven as well. It tends to come around 1 to 2 weeks after the infection. The high fever that comes on for 3 to 5 days suddenly disappears. So this is the condition that you're gonna be contrasting with. Kawasaki is disease. Cardiac is disease. The fever last for over five days. Where is Georgio? In phantom, you're looking at a fever that lasts about 3 to 5 days and goes It goes really, really high. A ghost over 40 degrees, usually and then it just suddenly just goes down. And then you get a complete edematous macular rash after this 3 to 5 days. So the chronological order is that the high fever over 40 degrees comes on for the first 3 to 5 days, and then it just suddenly disappears. And then this sort of rash appears and 20. You can tell that this is a rosiana in front of limiting. You want to do the basics. Basically, OBS want to rehydrated this patient and, yeah, just just the support of management basically and roseola in front because off it, if it's high temperature over 40 degrees, the the child's brain is not really able to compensate and be able to handle this sort of high temperature. And so you get this fibrillation versions due to the high temperature fever. Convulsions are not, as I mentioned, are not always sinister. Cause of they just happened because a child's bring country we handled the the heightened, higher loved and pretty changes. And so they have to have the going to spasm old itself, resolving again self limiting And, yeah, just do observations. So we have just two more questions after this and we'll be done. Think we're on. We're on track. Yes, cervical lymphadenopathy would be bilateral here. I can't to be unilateral million cars sake. Sixties can someone not to support Yeah, intestine. So this is a slightly tougher question. And let's see. Yeah, it's it's a split slit in in until let's just give it a few more minutes. Um, a second. Sorry. All right, let's stop it. That majority of you guys have gone for the hand foot mouth disease, followed by, See impetigo. So let's break down this question and try to understand what? What exactly is going on here on? We'll go through a few s B techniques in the process as we try to break it down. So the right answer here is actually impetigo. And so this boy pizza in your body is coming in with hematuria. So hematuria already has in mind going to it's renal problems. Renal manifestations. Now, his mom said that he had an infection about two weeks ago when he couldn't go to school on the emergency department. Specialist identifies that this is a sequel it to that infection that he had two weeks ago. Uh, no. The the arena manifestation that I'm talking about here is actually post streptococcal glomerular glomerular nephritis. You seeing hematuria? Which is why you see the material. But if you go if you eliminate slowly the sort of options seborrheic dermatitis is caused by a fungal infection malaise due for for you don't really see hematuria with fungal infections, especially on the on the under, the dermatological on the on the surface of your skin. So you're not really thinking about this Scabies, is it? Might. It comes and boroughs into your skin. You don't really see hematuria, and this is, well now molluscum contagiosum. You might be wondering what exactly that this Let's move onto the next condition, and then we'll try to compare. But But I go and molluscum printed contagious. Now hand foot mouth disease is caused by a viral infection. It doesn't really say the stem that his hand they were also so They were small, sort of popular in his hands and legs on an oral involvement as well, so you can kind of rule them out. Molluscum Contagiosum is also a sort of lesions on the Donnatal on the surface of your skin. It's usually one main lesion, followed by multiple panels all around. Um, it's not really, in fact, infective. That could cause hematuria, so you sort of rule it out in particular But if you know the background off, But I go the main cause this stuff or es. But a second request in protectable these golden crusted lesions is actually group a strep. And that's what I mentioned. This group is strep is very little and causing loads of different complications. So now this group a strep is what is causing this post primarily on after a script for streptococcal glomerulonephritis. And this is the, uh the way that we try to work out this question. Now I have a question for you guys. Group a strep I mentioned is a very, very sort of a little bacteria. Can you name a few conditions? That group a strep could actually cause Yeah, you're correct. Scarlet fever. It goes in through. Oh, we're going to go through. Sorry in, but I force the second one. We went through tonsillitis. A swell Don't like the cellulitis too, right? Rheumatic fever? Yes. Correct. So room. And it could cause a neck fascia. This but romantic fevers also something that a group a strep because and all you must be thinking all these sort of causes off infections off group A strep could cause post streptococcal in America nephritis. So that's something that you need to have at the back off the mind when you're thinking about you material or post streptococcal glomerulonephritis. Now let's go through these few conditions that we're just, You know, this this question hadn't put more disease. It's caused by a Coxsackie virus. One of one of the main complication of Coxsackie virus is my card itis, so make sure to have a listen on discrete for any chest pain. Obviously, a few weeks after this occurred, more diseases well, it just re presented tightness. Sonus Dry cough actually raised britches. Now the main key features for 100 modern is is is basically painful mouth ulcers and listers all across the board body, especially the mouth and foot foot. Uh, as it's a zit says on the tin. Uh, so you diagnosed it. So your diagnostic clinically and it's just supportive management, and you tend not to share materials because it is contagious and it can pass from person to person as we talked about it. Molluscum contagiosum. It is caused by the virus, not a bacteria. It's this small, flesh colored popular with a central difficult you can see here, there's a central dimple followed by flesh colored popular, uh, you you you don't really do much to it. It's not very sinister. You just go through a supportive management, but you make sure that people are not sharing. Towels are not sharing sharing materials together that are not watching all your clothes together. These are some things that you need to screen for when I'm going to go ahead with the disease is the smallest can continue to use. Um, if there are super infections that cost by this virus because of repeated scratching or practice you didn't treat with topical juice. It casted are oral look oxylate. Now let's talk about seborrheic dermatitis. Seborrheic dermatitis are infections off the oil producing glands or the sebum in the on the on the skin. It's usually in New unit on Children. You noticed this sort of cradle cap appearances. I'm showing here. It's sort of a uh, it looks like a cradle. It looks like a cap on the on the on the baby itself. It's caused by, as I mentioned Molly say the for for I don't know if I'm pronouncing it right, but the management for Seborrheic dermatitis in a baby would be the first line is baby vegetable or vegetable oil or olive oil. Uh, and if that doesn't work, you move on the white petroleum jelly, and if that still doesn't work, you move under anti fungals. Such a club tribe. Try mometasone or miconazole. Oh, in adults, it's the same management as and dandruff. So you'd give ketoconazole shampoo of topical steroids. Obviously, you'd ask them to keep, uh, keep a good hygiene, constantly washed get troubles, or the data that loads so that it doesn't spread out doesn't recur. A nappy rash is mainly due to a contact dermatitis, but it could be caused by a fungal or re bacterial causes. Well, one t respect is that oral antibiotics. So if the baby is having a neck or or steps is obviously you're you're more worried with the necrotizing enterocolitis or sepsis. But this type of antibiotics treated disposed this you to a candida infection because it's it's sort of suppressing the bacteria and sort of the the the fungal infection can actually, uh, grow in this region. You notice so inflamed red region red regions around the nappy around, whether nappies, war and in in in infections that haven't been treated very soon. You noticed this erosions and ulcerations since so the key of management principals weren't happy. Rashes are you switched to high absorb in nappies. You try to keep the area dry and clean, or you don't eat the night before or try to avoid wearing the nappy for a longer period of the day. You wouldn't want to use alcohol products to clean this because it would irritate the rash even more so. You use gentle alcohol free products, and the key thing is, do not buy this snappy, uh, trying to avoid wearing it for the pier off the infection we talked about scabies of it is caused by this sort of mites. It goes and Barrows in the skin on you. Notice a small red spot Track marks, especially between the fingers. As you can see, it's sort of in between the fingers. The first line treatment is permethrin cream applied on the whole body. If that doesn't work and you can give or a live vaccine for difficult crusted allegiance and all contacts in this case need to be treated, uh, another key principles to remember for scabies is that, But once you give them this cream sort of apply, um, apply on your on your skin. You need to ask them to reapply it at seven and a 70 point just to make sure that everything is dead. All the mites, that dead in the skin. And this has to be done with the close contacts. A swell, um and we move on to him. But I got the answer to the question that we talked about. It's the first line. The first cause is stuff for es. But, um, you can get in with a group A strep as well. The the main feature for impetigo sort of golden crusted lesions. You can get it on the cheeks or around the mouth as well. It is highly contagious. So you you go for a school exclusion for, I think, $48. If I remember correctly, um, the management would be topical. Few cytic acid, uh, as a tried trying to combat the bacterial infection and these Arctic cream, which is also known as hydrogen peroxide cream. And if that's extensive disease, or you think that it's progressing, give or off, look up for Kocsis it in and this would be mainly to treat staph aureus infection. Right, Let's move on to the next question. Can someone launch the point you're doing? You guys have been really, really well, just I think this is one of the last questions thing has one more question after this. If I remember, let's give it a few more seconds. Give it a double of one minute for this question. All right, let's call it there. So 50% off you have gone for a deep with the rest of you 30% going for a and see and be close by. So, uh, the 50% of your you guys are definitely right. And let's try to explain how you can get the answer to this question without, uh, knowing exactly the symptoms and stuff. Uh, so in Israel and you notice this sort of Kreisel symptoms increased nasal discharge and you tend to panic because you don't really know what condition that this this question is talking about. So there are a few key points that you need to understand when it comes to answering SBA questions, and every sort of sentence is given for a reason sometimes they really not, but more likely than not, they're They're given for a reason. And the key key statement here is the child has not received any vaccines so far. So you're thinking off vaccine such as the six and one vaccine, the measles, mumps and rubella. Because this chalice four years old switch on one year old you received the measles, mumps and rubella as well as a booster at the three year and four months mark. And so you're thinking about these sort of vaccines. But measles, mumps and rubella are are not really one of the options here. So all the options here, if we see our 11 to the six in one vaccine okay, so we have not really down to the six in one vaccine here. Uh, let's go one by one. Tetanus attention is usually the classical presentation is a soil injury injury that that has exposure to the ground, and you don't really see this year you're noticing a bit of corrosion symptoms and cough, so it's not really something that you could think about produces. Let's let's move on to be there's no whooping cough produces the cause of this sort of pattern ammonic whooping cough. So you you don't really, really see a whooping cough in this in this scenario, so you can rule that out Also. Now let's move on to polio. Polio is a virus. There's a gram gram stain in here so it can be polio because there is a gram stain. So you're stuck between Hemophilus influence. There be and diphtheria. No hemophilia in influence. Influence it be is a gram Positive caucus. Uh, whereas diphtheria is a gram positive fraud. So it's basically narrowing it down between HIV and diphtheria and one of the symptoms with him A pill. It's influenza B Asnis mentioned in Children. You notice this sort of a big long time This picture where the child is transporting and this is the start of keywords aren't really being used in the question. So that's right. You can narrow, narrow. The answer is not addictive diphtheria. But if you knew the symptoms of thinking go straight to dictate. So these are some key dips that are useful really understanding and choosing the right answer. When you when you sort of look at the question right, so we're just going going to go through, produces and moving, and we have just one question off this. So if you just hang in there, I see the church bells going. So it's nine o'clock. We'll just be done in in 2 to 3 minutes, but uses bacteria. It's not really common because majority of the people here are vaccinated with the six and one vaccines off produces is the grand negative and capsulated where it's 50 years ago Opposed to road? Um, it's a Kreisel symptoms and low grade fever with Inspiratory Group. Now keep oint a member with this weeping cough is that Children who have this will be a cough, as this showed in the respiratory section of this, he showed a fantastic with video and the sound of the whooping cough. It's off these these Children, actually, because of the increased amount of coughing, because because of the increased amount of energy entitled volume that they put into the cough can actually end up fainting or having syncopal episodes on. So this is a very sinister cause, and they need to be admitted when this happens, because, uh, you know, with supply itself oxygen, so think about this type of things when you see the the the, uh the intensity off the whooping cough in stuff you need to admit them, and you need to sort of manage them with oxygen and observation. In these are very short. Straw is used as the PCR testing and greater than two weeks. You'll be able to notice this, and they produce the stocks in high gear. But that's not really relevant because you're the whooping. Cough is generally seen in the first week to remember. It's a notifiable disease. And since it is a bacterial because you go from a macrolide, it's a slightly more important sort of Yeah, uh, as diabetics Remember, we talked earlier. Gentamicin was used to cover the grand negative, a bit of gram positive, but gram negative. Generally gentamicin is a macrolide. So about macrolides can be used for a grand negative encapsulated back to you. And if it really, really doesn't work, that could dramas is all it's always there. Aqui complication and produces is bronchiectasis, but this is more of a prolonged complication. Diphtheria. You noticed this sort of cold nasal discharge as well as a purely and, uh, this charge and has a slowly progresses you know this even bloodstained discharge. You take a culture from the nasal secretions to diagnose it. And again, as I mentioned, macrolides are really useful in in this sort of my name's mint. Uh, you want to give a single reading for singles of the area? If a child who's vaccinated has got a diphtheria, you don't have tried to convince a child who is in vaccinating convincing parents, too sort of. Get this, get the vaccine as well. And remember that for the diarrhea, you need to give a little mice it for contacts and certain complications that could arrested your cardiomyopathy in Uropathy. And that Friday, which is a relatively rare but it still seems right. This is the last question. Um, I promise. And then it's just for selection, or so that will be sending to you. You guys are doing really, really well launched a pool. Just give it a few more seconds. Well, just sorry agenda. My son is an aminoglycoside, I accidentally said macrolite er I mean of lack of states and mackerel. It's, uh, tend to be mixed around with the grand negative. Maybe, but Grandpa was a difference, so you can be given especially mackerel. Oh, it can be given for gram positives to cool. Let's stop it. That majority of you have gone for be followed by a followed by. So, um, this is a key principle that you need to understand as long as you see a kiwi doesn't mean you just go straight for the answer. So a new one baby is examined by the pediatric register and you notice a flat big patch on the top of the baby's head on the flat pink patch. So there is a key whether it's given here, that the baby was delivered by the end user parentis, which is a sort of suction that it comes and tries to remove the progress the baby, especially when the baby is not progressing. And you try to use Advair and use, or you try to use forceps delivery. So the key complication of Mentos deliveries are couple accidentally, um, careful of hematoma, a stroller intercranial hemorrhage. But however, all of these are raised lesions. So a fellow hematoma, you notice A. There's not usually a discoloration, but you know this because it's just below 22 layers below did the dumbest. So you know, this sort of protruding bit on the top of it. Succeeding, um, is a sort of a patch that you notice, which is very red, but it is still raised in the cranial hemorrhage. You can't really you can't really tell, but it is a complication that they would get any disconcerted management. But it's a stage, so you're stuck with instructor. Any pus in salmon patch Now, strawberry nevus is again, not flat. It is a raised, a sort of nonpathogenic lesion that a baby is usually born with, while a salmon patch is again not non pathogenesis. What a swell! And it is just a birthmark. So the right answer here is the reason. The reason that salmon patches the right bounces because it's a big patch that is completely flat. Okay, so just because it's a renters delivery doesn't mean that you're straight. Go for comfort. Succeed in your mark. Have Paloma to consider the options, read the question carefully and then try to answer it. This had a subset of tricks that they try to bring it in exams so salmon practice are just birth marks that cost with tiny blood blood vessels. It's usually on the head and on the on the scalp. It they tend to fade by the 1st 2nd here, and they're really, really common. Uh, as I mentioned the pink red flat. Any regularly ship, the self resolving, and there's nothing that you need to do. They don't cause any future sick, will it? Strawberry neighbors. As you can see, it's slightly raised. Here are blue or red patches. It's usually on the head or the neck, and an intervention is needed if intends to stop obstructing the nasal spray or the bridge show pathway. The involutes mundanity, which means the results wanted it spontaneously. But if you notice a rapidly progressing strawberry nevus, you want to give propranolol as a prophylactic prophylacting that as a treatment option for a rapidly, rapidly proliferating one, right? And just a few post lecture notes on the vaccination schedule. This is the most updated vaccinations schedule. I believe it is the June 2021 vaccination schedule. There weren't too many changes, but yeah, for all those who wants the most of operated one, uh and is well assay. I mentioned the exclusion criteria for school. Uh, so with that