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Paediatrics Lecture

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Summary

Owen, a medical professional, will be giving a comprehensive overview of pediatrics, focusing particularly on musculoskeletal (M SK) medicine. He will review essential concepts such as the 'limping child' and its differential diagnoses, delve into the examination and management of critical conditions like septic arthritis, and explore primary bone cancers in children. The session intends to prepare attendees for exams and equip them with the necessary knowledge to deliver effective pediatric care. Attendees are encouraged to participate in interactive activities like multiple-choice questions and open discussions.
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Learning objectives

1. Develop a comprehensive understanding of the diagnosis and management of septic arthritis in children and its representation in the limping child. 2. Gain insight into the various serious conditions that may present as an acute limp in children and the need for rapid identification and treatment. 3. Understand the presentation of primary bone cancers in children, their signs and symptoms, and the importance of swift diagnosis for treatment. 4. Recognize the signs of potential abuse or neglect resulting in injuries, such as fractured femurs in young children, and the appropriate actions to take. 5. Develop a plan of work in a clinical setting to assess and investigate a limping child, including communication with the child’s caregivers and coordination with other healthcare professionals.
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Computer generated transcript

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

Hi, everyone. Thanks to everyone who's logged in there so far. So I'll just give it another couple of minutes to let a few more people in and then we'll make a start. Alright. Hi. Thanks to everyone who's joined in there in the last few minutes as well. So I think numbers are still going up there, but I think we'll make a start and obviously everyone then can just join in whenever they're able to. So I'm going to start here, I'm just going to share my screen and if somebody could unmute or just give me a wee tape in the chat just to say that if you can hear me and if you can see my slides and that they're moving. Alright, great. Thanks a million. So, make a start. So you're all very welcome. And thank you all for tuning in tonight. My name is Owen. I'm one of the, the final E and so what we're going to do tonight is hopefully just take a run through pediatrics, which as I'm sure you all appreciate is a massive topic, but it is one that is assessed quite heavily on the, the final style. It'll be the A KT paper for you. And also obviously in fourth year os it's one of the big topics in fourth year. So you'll definitely be expecting at least two stations on it. So hopefully we can, um hopefully this talk gives you a wee bit of preparation for that. If at any stage, you have any questions, I'll try and keep an eye on the chat, but as well just feel free to unmute and shout out and interrupt me as well. So this is what we're going to go through tonight. So I'm going to have a look at these first few topics here, endocrine derm, some M SK stuff and also neonatal. And then on Wednesday night with Nicola the second part of this talk. So we're looking here at some of the, some of the big hitters and peds, cardio respiratory gi and infectious diseases, which I also cover a little bit of tonight. So thankfully, that's our list and not, not this one here. Um However, this is, this is taken straight off the GMC S website on what they say you need to know as part of this UK MLA that you'll all be sitting and as I'm sure you appreciate, it might be a good reference point. I'd certainly go through this and some things you need to know more than others. But I suppose this is just to give you an idea of some of the conditions that we're going to talk about tonight and hopefully as well just to give you a chance to guide any bits of revision you're going to be doing for the exam itself and also for the acies. So, moving on, first of all, just to look at musculoskeletal medicine, impedes. And really one of the big topics with this is this concept of the limping child. So really big topic and it's very examinable in both OS and an M CQ style paper because there's some really key facts, you need to pick out of the history and also the examination to try and make an accurate diagnosis. And unfortunately, this is one of these topics that does have the big diagnoses that people would say you can't miss um lots of differentials, as I've said. And really they depend on two things, the clinical condition of the child and also the child's age are the two big things that will help you um tell the difference in this, in the history. So I'm going to start off with an M CQ just to get a wee bit of practice. And I know everybody seems to like the M CQ. So you have a read through that. And if somebody wants to any all you want to type into the chatter on mute and let me know what you think about this and what the answer would be. Yeah, so well done there. So with one answer and so the answer correct, certainly based on the information that you have. We'd have to assume this is a case of septic arthritis. And as a little exam t maybe not as true in real life, but I certainly treat it this way in your ay as septic arthritis will be the answer in these questions until proven otherwise or by which, as we'll see. So as it applies, as you maybe have had talks about this in rheumatology, orthopedics, infectious diseases, things like that in the adult sense, it's a medical emergency. It carries a high mortality and really the big thing about it is it is usually one infected joint that can destroy the joint itself very quickly and then that infection within the joint can spread to the blood and then hence the septic part of the, of the um of, of the name of this. Um it presents as a red hot, single swollen joint and really to simplify the management of it, you would be looking to aspirate this ASAP and preferably before your antibiotics as well. Um This is how I would typically present. Um So it typically presents as a red hot swollen joint. They're going to have a reduced range of motion in that leg and they're also going to be systemically unwell. Now, I did take this from uh from an adult presentation. So again, things like staphylococcus aureus um would be the most common organism that would hold true in Children and also things like e coli haemophilus influenza and group A strep as well, would all be some of the common organisms that you would consider in the case of especially younger, younger Children and teenagers as well. So in terms of investigations, then usually they're going to have a really high white cell count and a raised CRP. This is because you're gonna have the single, the definition on your exam or the, the light on your exam that could really sell. This would be if there's a yellow or pus filled aspirate. If somebody had attempted to aspirate the joint as well as things like a tachycardia tachypnea, hypertensive, it gonna be pyrexic, potentially a low sat and a high lactate as well. So in terms of treatment of this, so really regardless of the organism, you would treat this empirically, which means without necessarily waiting on cultures or any blood tests to come back prior to your sensitivities being confirmed, you can then obviously move to um say you would move to treat this more targeted to whatever organism has grown and have a very low threshold for starting this treatment. And again in your osk and an Os, I would always say that, you know, you would again, better to start this treatment and have it not to be necessary, learn to get yourself in a position where you've suddenly let this go a couple of hours without any treatment. Because this, this process that I talked about with the joint destruction can actually happen within about six hours. So you really want to, I suppose, treat this quickly. As I said, a long course of antibiotics, you'll be admitting these Children for the antibiotics and then you could potentially look at AP O switch down the line. This is one of the things that was written at you. I've heard it talked about in adults as well, but it was actually written specifically for Children and to try and differentiate between septic arthritis and a transient sinusitis and as the cocker criteria. So again, if you, if you learn off these four things and are looking through, say the stem of the question, you know, if you have any of these things really, that would be suggestive of a more septic picture than a transient sinusitis, which is a much less severe condition. So really as I said, the four things here go without saying, so they're nonweightbearing, they have a temperature, they have a raised E sr which is actually the one that's preferred in, in preference to C RP in these patients. However, a raised E RP the see you would be, you would be along the same lines of thinking around that. And then a raised white cell count greater than 12 would all point towards and give you a score here in this Cocker criteria pointing towards the definition of diagnosis of septic arthritis. So, can anyone think of any other serious conditions that need ruled out and this is in the context of a limping child. So say you're in GP land and this child presents in with an acute limp. And can anyone think of any other serious conditions that need to be ruled out straight away or the might need same day assessment up in the ps hospital or how it would present? Yeah. So, so yeah, Perthes disease. I'm thinking as well as to any other. So yes, and it's great. You're all thinking along the lines of M SK, but there's a few quite serious conditions can present this way that perhaps aren't necessarily, you might think as an M SK condition. So it could be things like, yeah. Yeah. HSP. Good show. That's grand. So some really good answers and they're all things that we're going to be coming on to discuss straight away. So if I was to present somebody and say this as a child with these sort of x rays here, does anyone want to add to that list that we've just had and maybe give a suggestion of what I might be getting at here? Yeah, there we are. So indeed. So these here are two examples of primary bone cancers which was extremely rare, unfortunately, do present in kids and can be quite obviously, quite devastating diagnoses that need to be treated quite quickly. So this here at the top of the, it is called a Ewing sarcoma and I wouldn't get caught up in any of this. But certainly when I was in third year or fourth year and we had to do third year and we had to do pathology exams. This was the one that was always sort of associated with younger kids. Again, these, these kids will be systemically unwell and some of the things that are really going to sell you. This is a serious diagnosis is waking up at night, the pain, waking in them at night. So night peeing, having these anorexia and night sweats and all these symptoms that again, even in an adult, you would be thinking the alarm bells would be starting to ring. And again, this one down here is an osteosarcoma, a very aggressive sign of cancer. And that's just a particular evidence of a thing called the Starburst sign, which if you've seen that on an X ray working in Peds or an Ed or anything, you would be very worried for that child. Um So does anyone know potentially? So and again, I'm going to believe that and come back to it potentially. But does anyone know what this could be indicated about this? This is obviously a fractured femur, does anyone know? And so say this is in a child that's 23456 months old? Yeah, absolutely. So this could come in A I is what I'm looking at there and that's of course, if that was to present to the GP, that would be the same day assessment at any age if you suspect or anything like that. And what I mean by the same day assessment is you would refer up to them and say you would in your osk, say you would refer up to say the pediatrics unit at the local children's hospital and have one more on this slide. So I appreciate this isn't an adult, but it's a rash of a condition that can affect adults and kids and can present with um quite commonly with bony pain in kids as well as some of these other symptoms, which could be a clue for you. So say this is, it starts off as a per rash. The kid might have bleeding gums as well is another sign scurvy? Ok. No, that's a good shout and I appreciate this is quite a challenging image because it maybe isn't the sort of right. You wouldn't think this is how it looks, but it actually is, I suppose just to um look, this is actually the rash of somebody presenting with leukemia, which and again, if leukemia is allowed to progress and you have these dysplastic blood cells in that actually get into the bone marrow and displace the healthy cells, you can does present with bony pain and a limp and sort of this perfect ration. And again, I probably should have made more emphasis on this last bullet point here. A perfect rational is same day pediatric assessment to rule out some of these conditions. So I suppose the point of this whole slide is really, you know, whilst you probably are looking at an M SK cause and hopefully you are in a lot of sense, just always bear in mind these and don't ever forget to ask your systemic questions. It's like how the child is any rashes, um eating, drinking, peeing, pooing all those things and then your systemic symptoms here that I've talked about really important in a ps history to go through that presenting complaint and a full, trying to do as full as systemic inquiry as you can would be one of my big, big um things to tell you. So I have a few stems of questions here as well and age is age is a big differentiator in all these M SK things and it was built in the land of M CQ. Anyway, I'm not sure if it may be just as black and white in real life. It probably isn't. So some of the things and again, these have already been mentioned. So say you have a question like this. So this not exactly not exactly a teenager, maybe normal weight, no trauma, no infective symptoms. And they're complaining of this sore right groin and they have a wee bit of a lymph bug going on as well. So, does anyone, could anyone tell me what the diagnosis might be there? So that's Perthes disease. And then if you say this 15 year old. This is really stereotypical of a, of a, of an M CQ question here. So that's a SUFI there. So really, if I would say that if I see this sort of age 5 to 11, I would be sort of thinking along the lines of this Perthes disease. And then if I saw a slightly older teenager and if, especially if I've seen this, that they're overweight, then I'm thinking that's a Sufi. So looking at Perthes disease. So again, if any of us have been through your fractures in adults, like in your fractured nega feur, the femoral head is prone to a vascular necrosis just by the nature of its blood supply, it has a poor blood flow. And then for, excuse me, a number of different reasons in development, what happens in Perthes disease is that you have this poor blood flow to the femoral head and it causes it basically, it dies off and you have this flattening of the femoral head and it affects how it joins in. Then with the acet up here and that is what produces and not really that poor fit really is what produces the limp and the pain. It is more common in males than females and it is um unilateral and more so and bilateral it goes through these four phases. Now, by all means, do not go and have to learn these. But I would say I personally think sometimes learning these stages helps get straight in my head and helps me remember what's actually going on and what I need to look for. So you have this necrotic phase, which is where like necrosis in any other process is poor blood supply. The bone dies off the bone. Then this poor sort of dead bone, then soft bone dies off and fragments. And this is where it causes the misshapen of the femoral head. And then over years of time, new, harder, more mature cortical bone is laid down and that takes whatever shape was formed here in the second stage. And then once it's finally healed, that's when the femoral head shape is final. Um And really the aim to look at this is to treat it when it's in a stage two or three so that it doesn't get to the stage of being a four when the hip just won't fit into the socket correctly. And then the child will be plagued with the symptoms that we've discussed there. Does that all make sense so far? Does anyone have any questions on any of that grand? So really what we're gonna say is so really to look at diagnosis, we can look at things like an X ray which we've seen in the last stage, we've seen an MRI which we can see up here and I'm by no means an expert in radiology or anything like that. But I think hopefully you can appreciate that there is something a little bit groovy going on with this left hip here. And that again, could be indicative of a Perthes disease. Whereas on the right side here, you can see the growth plate and the head set much nicer with less inflammation around it in on the right hand side. And this here down on the left is a technetium bone scan and I certainly don't know how to read them. So it's more just to let you know that if you see that maybe in some of the text book, that what it is talking about there, it's one of those nuclear medicine scans. Um in terms of the management, it actually is more conservative than certainly, I would have thought. Anyway, it really does revolve around active observation and just getting these kids back in for review, looking at nsaids, physios braces can be used and very rarely surgical intervention can be used as well. Looking at a SUFI then. So what we talk about here is this, so the epiphysis is the area distal to a growth plate or the of the ie the epiphyseal plate here. And what it is is, is exactly sort of what it says on the tin. It's a slipped upper femoral epiphysis. So it's where you have this slippage here along the growth plate of the distal part of the femur. So you have the femoral head sitting and then obviously, you can see here on the left hand side that this left hip is very clearly out of alignment and I'll show you a little sign that can be used to help if you are uncertain about it, which you're presented with an image like that, an X ray and an exam. And it isn't a subtle again, the classic, the classic um presentation of this is a, is a teenager, male teenager who's a little bit overweight and the way I think of it as in, I'm a bit simple. I think about some of these things. Sometimes I think that if you're carrying a heavy box walking, you might be more prone to slipping. So that's how I want to lose the We Memoir. If it helps anybody else, I'm not exactly sure. Um Looking at exam findings then. So it is actually quite similar to your fractured, like a feur presentation. They like holding the leg and external rotation and it may well be shortened, they're going to have sore internal rotation. So almost again, percent make a little bit of an arthritis picture and they're going to have a disproportionately bad limp and be very painful after what might be a fairly minor trauma to that area. Looking at the the diagnosis. Um So they can be acute so they could be failing to weight, bear for less than three weeks and it can be actually be chronic. So you can have this vague hip pain or groin pain presenting to you for more than three weeks. And the diagnosis can be made on X ray. And again, it just so you can use this uh this sign. So if you were to draw a line from where the greater tranter meets the neck of the femur, it should just touch the edge here where you can see, sorry, it should go through the, it should go through the hip like this. Whereas on a slipped upper femoral epiphysis, that line that you draw from the greater tranter along the edge of the neck of the femur won't come into contact with the femoral head or it will just clip the edge of it here as you can see. Again. I think I would like to think if you had, if you had something like that, it would be a lot more obvious than that, but just in case it's something to bear in mind in more where there is more diagnostic uncertainty. You can also look at things like CT scans MRI S and just bear in mind though as well with all this, like the need to sort of consider radiation quite carefully for kids, especially where the, you don't really want to be scanning kids with CT S and X rays more than you have to obviously just due to the lifetime, the cumulative like long term lifetime exposure to radiation and the management thankfully, you'll be glad to hear. It is fairly simple and it is unfortunately for these kids and teenagers, it does need to have an operation. These are unstable injuries and quite often the, the management is just a cannulated screw here, similar to what might happen in a, in a hip replacement or in a, in a, to repair a neck of a fractured neck of feur. Just a cannulated screw here as can be seen in both both sides. Actually, I'm not sure if this is maybe like a prophylaxis on this side. But certainly you can see from the shape of this patient's right hip. He's had a slip there and the screw has been put in to tighten that joint up. Looking at a different, she'll hear just for those sort of older kids or teenagers presenting with pain. And this is usually seen in these are your footballers, your rugby players, things like that, active teens complaining of this sort of diffuse and chronic knee pain. It's an important differential and really what happens is. So you get this quite characteristic hard lump on the tibial plateau and examination a tibial tuberosity where you get this, it's constant swelling and recurrent swelling and inflammation of the patella tendon that causes these sort of wee mini fractures of the tibial tuberosity. And over time, these fractures ossify again and cause this sort of disordered bone growth, which is what is felt as a lump thankfully quite often. And in fact, in 99% of the cases, there's no operative treatment and it's just rice nsaids and some physio as well can help strengthen especially the the quad muscles and the muscles around the knee up to help prevent that from happening. An important thing to consider as well with kids at these Salter Harris fractures. So and thankfully, this image you'll be glad to hear will explain things a lot better than I probably will. So if you just remember your mnemonic of Salter as in the name here and remember sure, your type one is where you have this sort of slippage straight across which as we talked about SUFI is a good example of this. Your a your type two is above, your type three is lower. Type four is through and type five then is an erasure or a crush injury where the the growth plate disappears, which as you can imagine, it wouldn't be good in a child that's still growing and hasn't reached their adult height yet. Again, the commonest type of these injuries in kids are um type twos around 75% and they're non operative. So again, if you just remember the higher the number, the more severe things are going to get. So type three and four, they're usually or ups so or open reduction and internal fixation of the injury. And type five, then a of the growth plate can be very severe and can, as I say cause a rest of bone growth. So thankfully, a rare type of injury, but one you definitely wouldn't want to be having. So I have another question here. So, so you're the F two in P ZD. And the mum brings her six month old boy in who took a fall while it's cruising along furniture. Uh on exam, the patient's humerus is bruised and the x-ray has confirmed a aa or high type two fracture of the proximal humerus. So what's the most appropriate in maybe initial investigation that you should have based on the information that you've been given so far, it's been a wee bit. I mean, with this one, I'm deliberately looking to catch people. So don't be, don't be, don't be afraid to answer because I'm sure lots of people will be thinking the same way as you will. Yeah. Brilliant. So everyone hasn't been caught out so well done. And if any, anyone that has given the answer c there does anyone want to give sort of the top on top thing on your differential then at the moment as to why you're choosing that? Yeah. Brilliant. Well done. So, exactly. So, and if anyone really wants to go the whole hog gland, does anyone know what in that history points you towards an N A? Oh yeah, well done. Everyone. Well done, Mary and Ruth. Um Yeah, cha is not going to be, unless they're the prodigy, they're not going to be cruising very unlikely at six months to be age that's usually in and around sort of 8 to 12, 89, 12 months, 89, 1011, 12 months before a child's doing that. So again, another big tip in an ay and they will try and do this to catch you out. Just learn. I wouldn't say by all means, learn every milestone. But what I would say is learn the basics of your motor milestones because bruising they will, they could potentially try and catch you out with say bruising in an noob infant. You know, the child was up walking at eight months or the two month old had rolled off the bed or the eight week old, six week old baby that rolled off the bed and things like that would all be raising alarm bells for you. So well done, everyone, you've caught that one out. So I just want to talk about this as a topic because it can come up in an a it was one of our stations actually in fourth year, last year was um and certainly a challenging station so it could come up again. Um, a big part of the history here would be piecing this together and piecing the history together. And it's really, really important in these auscultations that you take a very non accusatory accusatory tone that you're very open minded to other differentials and that you get your, that you say to the examiner that you'd be getting your seniors involved early. Um Inevitably the patient will turn around and ask. So it's ok, can we go home now? And so just the advice would be to practice having that conversation with your friends or talking in the mirror, having your ay practice and just have that conversation around explaining that you'd like a senior review to, for example, make sure that the child is getting the best care and that they're getting a thorough review and things like that, you know, without obviously letting them go being unsafe and letting them go home, but without also making accusations that you by all chance wouldn't have enough evidence to prove at this point. So as I've said, look for the bruising in a nonmobile infant. And what I like to look at in this is and really think of this, these sort of stations who, what, why, where and when. So really some of the things that you want to look out for in this now, I apology, I probably could have pa these notes out more slightly. But so you talk about who was with the child, who saw the child and who has access to the child. So again, whilst, you know, without wanting to be, without wanting to be stereotypical, a lot of these stations can be written from the perspective of say mum's new boyfriend or mum's new partner that, that um you know, it could be dropped into the history and from memory, you know, you know, that can and does come up in in their station writing So you want to talk about what happened and again, piece that back to your motor milestones, put post it back to all your developmental milestones and see really and just even common sense as well does what they're saying, make sense why they've came. And what I mean by that is maybe why they've came to Ed. Because, you know, the research has shown that these people that you are guilty of neglect and that are repeat at tender and repeat offenders of this tend to go to Ed because they perceive it to be more likely that different doctors will be rotating through, you're less likely to see the same doctor. Whereas of course, if you're in a GP, that there is three or four GPS in, well, then you know, the odds are you are going to be seeing that GP. If you know, if you know these na A cases keep coming back to the GP, you want to talk about where it happened. So for example, if it was say in the living room, if the child had been left unsupervised in the bedroom and the bathroom, things like that can all help paint a picture. And when did it happen? And in particular, if there was a delay, why was there a delay and why did you not seek help? You know, as soon as you, you know, if this child was in pain, two days post injury, there's a good chance they were in pain earlier than that. And just in a non accusatory way, perhaps ask and hear them out on their explanation as to why they haven't done this. And again, being non ACUs open minded is all these soft communication skills in this station. They again will score you very, very highly as I've said here. And we really, we've talked about all this here. So multiple ed attendances, different staff on these changing stories and vague stories and implausible stories. So as we've said, so if maybe mum said one thing, dad said, the other thing, um somebody, you know, mum comes in and says, oh, he was with somebody else or you know, she says, oh, you just fell and won't elaborate on any more details than that. Uh delayed presentations as we've said. And kids being too familiar with strangers and very distant with their family can be a sign of long term neglect. And um indeed, familiarity will be not in keeping with developmental milestones. So Children do have that phase of the development where they do become smiles, they smile at strangers. But there's also a point if you look at where they make strange as well. So again, more chronic neglect could certainly unfortunately present in this way. So and again, without wanting to labor the point, too much, the exam needs to be done by seeing your pediatrician by consultant. Really? So you'd be doing that and getting them involved extremely early in these cases, but you can make a note and, um, if you were asked, you know what you would be looking for, you would be looking for bruising in suspicious areas of the body here. So you can see in this poor child here behind the ear, this sort of quite teardrop shaped bruise on this child looks like a thigh that could be things like being struck with a cord or with a coat hanger. The other ones could be things like belt buckles, bite marks, things like that. And you just look for, you know, the pattern of the bruising as well. It can be indicative of things like this. And as I've said, in terms of your management. So, you know, first thing, you know, as a doctor, you know, do no harm, you do best for your patients. You want to ensure that the child is in a place, tell them you would have your child in a place of safety. Um You really want to, you want to make a body map of the child's injuries. And again, this, you know, this is the management. It will be a more senior making this decision. But nonetheless, I would definitely tell, say as part of your management and by all means, say all this, you would want to get medical photography involved, you would want to look at a co a screen and you would want to look as asked to investigate any potential underlying pathology and this would all and a skeletal survey on CTB as well. Um So, and this all comes back to this point about comprehensive note taking as well. You know, unfortunately, there's a high probability these sorts of cases could end up in court and um, you know, your note taking. And indeed you as, as the doctor that saw the child could potentially end up having to give evidence and things like that. So I suppose just that's the rationale behind being really thorough with all this. Um So you'd also want to look at an potentially an ophthalmology review of this patient. And does anyone know what you're looking for and what it's a sign of that you would be wanting to get the the the eye doctors involved? Really? And yeah, so Marian Ruth, so you've answered the two of you has answered that question. One's given me the sign the retinal hemorrhages and the condition then is quite often it's seen with shaken baby syndrome and it can also be seen with other traumatic injuries in, you know, in an older child that has sustained a head trauma as well. Um And again, just to really add a wee bit of flare to your answer and show you really thought about this holistically, you might, you would say that you would also consider a referral to perhaps an emergency social worker or you be on call social worker to consider the risk to any siblings or if this family are maybe known to social services or things like that. Unfortunately, it's worth bearing in mind all the different forms of N A that can include sexual assault. So, you know, if there was a referral that needed to be made to say the Rowan Center, which is it would be the Regional Center here to my understanding and also just to the multidisciplinary team, they are really involved in things like social workers, the police, child, safeguarding agencies and things like that. Um Super well done. Um So does anyone have any questions on any ads so far? I appreciate, you know, it's a heavy topic and we're doing well to get through it. But does anyone have any questions for me or if you'd like to unmute or type into the chat or anything like that? Feel free to do? So super. So we'll make a, make a start on then to dermatology, you know, everyone's favorite as you can see it. Certainly this guy's favorite here. Um And the classic one, you know is the eczema. And so you are probably thinking right, as if we needed any more evidence s gone mad. And let's just put a picture of a random brick wall in the present. But actually the bricks and the wall counseling system is really useful in, I think in explaining, explaining eczema as a condition to to kids, older kids, you know, you could use this with and indeed their parents as well. So the way I like to consider this is, I'm sure people have heard of it, you know, all jokes aside. But if you haven't, so the way I like to explain this, so if you imagine our skin is waterproof much, like you would hope that the outside wall of your house is. And what happens in eczema is, you know, in a healthy skin where you have the bricks, the sails in the skin and then the cement acting as the waterproof barrier. What happens in eczema is for whatever reason, one of the reasons of things like urin allergies, things like that can cause allergens when they react with the skin can cause the breakdown of the cement, which is the waterproof barrier of the skin. And obviously, if you were to waste away at the cement on the brick wall of a house, water could get into the house and cause a flood. So it's much the same with the skin water. And other saying can get into the skin once this barrier has broken down and cause the symptoms of itch redness and just general symptoms of eczema. Um commonly seen traditionally on the flexural surface of the on the flexural surface of of of the, of the body, you know, traditionally in the crux of the elbows and the antecubital fossa and also in the popliteal fossa of the knees, it can be seen in the face of babies as well. And again, it can affect really much wider sites as well, so it can affect the hands, the wrists and other sites of the body as well. This here is a really good, really nice succinct description of the pediatric guidelines here using this link from a trust. And it does again, if you want a real brief summary with some nice graphics as well, I would have a look at that your management of your of eczema. So um as I actually read and read in a book written by a doctor there, that wasn't a dermatologist, you know, the golden tenets of dermatology, it's dry, make it wet, if it's wet, still make it wet. So really the mainstay of your treatment to this is emollients and you want to apply these liberally and you know, you know, they don't have to skimp on these and it helps really emollients are artificially replacing that cement that we talked about. And that's how you can link that in with your treatment that you're replacing that waterproof barrier, the cement that we talked about in our analogy and preventing any irritants from getting into the skin in the first place in the line. What has been damaged to repair itself to the body's natural mechanisms like the steroid ladder. There also is the emollient ladder and they range from thin to greasy, thin to greasy. So right down at the bottom here, you might see some of these things that you can actually, you can get on prescription, but you can also get in the chemist, things like E 45 and then you're going the whole way up to things like epiderm double base as well here, debase and also right up the way to paraffin. So it does, it is worth counseling your patients if you are really going to go in depth to emollient in your counseling on these conditions that you want to counsel them around applying them liberally. And as, as a general, you would go as greasy as tolerated. Now, the the offside of greasiness is that they can linger a wee bit longer in the skin and they also could be potentially brewing your clothes. So it's worth making sure the patient is aware of that and happy enough before the start next step up then. So you want to use topical steroids and really forget everything that I just said about emollients about using them liberally and all the rest and using them continually. You want to treat as per the latter to control flares and you would really want to use these for a short, short a course as possible and using as little as possible. So talking about this fingertip unit here, so the top we digit at the top we um fall of the finger there covering an area, you know, the size of your hand or more. Um And again, you make a note of the steroid ladder here. So things like your hydrocortisone cream, sometimes that can even be bought, you know, over the counter right up to their Dermovate, um would be one of the ones that would be extremely potent. You know, you would be wanting to counsel the patient very carefully on, on their use next line. Then you're looking at things like wet wrapping, you're looking and that's involved. That'll be really getting to your dermatology nurses and your multidisciplinary team involved in that say your treatment room, things like that. And unfortunately, you would refer and all at this point to a dermatologist looking at psychology and po as well actually can help look at breaking this itch scratch cycle that as we know, unfortunately, itching, it is a vicious circle in these kids and this can be very effective in kids, especially who may not understand and rationalize the harm that they're doing to themselves through their, their constant itching as well as then looking now very far down the line of things like immuno suppressants and biologic. You know, if you worth mentioning at a glance, if you didn't want to be comprehensive, but again, I would be focusing with all your ay stations at engaging the patient or their parents level of understanding. I would be explaining what the disease is, how we're going to treat it in a broad sense, focusing on really good, have a good counseling station on a, on a good counseling spiel on emollients on steroids, maybe wet wrapping as well. And then just bearing in mind these other things you can throw in if you know, if you're saying you're not getting on control of things, is that all happy enough for everyone that's grand. So important to know about the complications of eczema. So if you look at bacterial superinfection of eczema, so this here you can see it, this awful looking infected eczema. You can see this sort of purulent pussy areas and obviously just a very red, angry looking piece of skin there. These would require topical or systemic antibiotic therapy. Uh Unsurprisingly with most skin infections, staphylococcal bacteria are the most implicated in this. And you would treat this usually with flucloxacillin, micro G A or the classic bailout in nos which I would recommend to everyone treating in line with local policy. Really important one not to miss is eczema herpeticum, which is a varicella or a HSV super infection of obviously viral not bacterial of eczema. And you would want to see him day a dermatology opinion, a dermatology or ophthalmology opinion on this. As you can see even it, it's hard to know if this is directly affecting the eye like an ophthalmic shingles. It's going right up near this child's eye. So again, this is somebody that you could maybe look at for at least mention an ophthalmology opinion. These kids can also have bacterial superinfection as well and you want to be making sure of this. So you would be um treating swabbing these for varicella and herpes simplex. And also, then you would want to um sorry, it's worth saying as well. The treatment with this, you know, I'm sure this is. Anyone wants to shout it out. I forgot to put it in. But if anyone wants to shout it out what the treatment for this would be or put it in the chat. So it would be Acyclovir would be your treatment for this. Um, ap or IV, depending on severity. So, have a spot diagnosis here. You know, the dermatology lectures. Love a good spot diagnosis. So, does anyone, again, this is fairly, I might give you, I'll give you a wee bit of background to this. So this is somebody who five year old, their weights from the seven the same. They have things like that and there's their symptoms and they've had a recent diagnosis of diabetes. Does anyone, can anyone join the dots together there? Yeah. Dermatitis, herpetiformis is right. And does anyone then obviously know the condition that I'm getting at here that this child has? Excellent. Yeah. Well done everyone. Celiac disease. Here's another one. So lovely. I didn't realize I was as big. Sorry if I've put anyone off their dinner with us. Um, anyone know what this is? Yep. And Bati, sorry, I muted myself there. Yeah, that's impetigo. So, and again, sorry if I've put anyone off corns for life. But it helps me memorize what it is, especially that nonbullous impetigo, which I'll discuss in a minute. So it basically it's a staphylococcal skin infection. It is highly infectious. And you would want to be counseling your patients on contact precautions, sharing of utensils and also giving them appropriate school exclusion advice, which I'll chat about in a moment. The difference in these would be fairly trivial but just to be aware, there is bullous and nonbullous impetigo. Um As you can see, these bulla here are, these are bulls that have burst, but a bulla. So you would have these sort of almost basically like large lesions. Whereas the nonbullous is this more traditional sort of golden crust like appearance. The management however, is broadly similar. It can be self-limiting. The first line is hydrogen peroxide 1%. But we have caution around the eyes. And that was actually a question in our prescribe and safety exam was impetigo affecting the eyes and you then had to go and look at your next line treatment which is um Fucidin is again, sorry for not writing that down, but Fucidin cream would be your would be your your next line for that. Um Oral antibiotics. There is a risk that these Children can become systemically unwell. And at that stage, you would be considering uh things like an oral or an oral, an oral flucloxacillin. Um So you can look as well at things like so I can, as I say, it can worsen and it can spread deeper into the skin with this probably horrific complication of staphylococcus called the skin syndrome. You could have a cellulitis or erysipelas and it can also become full blown sepsis as well. So certainly, while some people, you know, may think it is just a r it's certainly not to, not to be messed with and to be treated promptly if warranted just for interest only, I'm not going to go into that. But as you can see here, this is the case of staphylococcal is called the skin syndrome. And really, it is what it says on the tin, the skin looks very red, very angry, almost burnt looking, right? So this lovely rash here again, not exclusive to the ankle. But does anyone want to shout out or get involved in the chat and tell me some differentials I cannot miss if I see this coming in to say that quite often with these derm things into the GP surgery as the first line as the first contact with the patient or if anyone wants to describe the rash as well. All right. So if, if I told you this is a pic rash, then an example of a pic rash. Yep. Very well done. So HS PHP. Uh and some of the one we've already talked about actually, if anyone can remember it. Yeah, well done Alex. So Leukemia would be one of them, but as I said, certainly not an exhaustive collection. And the big one there that you really, really cannot miss on these kids is meningococcal septicemia. And that is an immediate, that's more than that. You have to act quicker than send those up to the, um, the Peds Ward. You're administering in those sort of cases. Even in GP land, you would have to be saying that you would be administering your, your, your, your IV Benzyl penicillin or other im penicillin. I beg your pardon. In the GP surgery, acute leukemia. Yeah, itp certainly can. Thankfully isn't as severe a condition as some of these other ones. But certainly one of your differentials in appropriate rash. So this which stands for hemolytic uremic syndrome associated with this type of e coli bacteria and often associated with petting zoos can cause this picture. So those Children do present unwell quite often and can mean renal failure and requiring dialysis. They present with hemolytic. So they would present with a low hemoglobin. They can be uremic. So have a high urea sorry on their U NE on account of the red cell breakdown and then have this uh which can also precipitate. Uh uremia is one of the indications for dialysis and kidney failure. Potentially sty strong coughing and vomiting can cause a non blanching rash, more petechia. And just to explain that. So a per would be this non blanching rash caused by capillary leakage from uh that's, that's bigger. And then pia is just the same only as those little pinpoint lesions. So that's just if anyone wants the difference in that. Um uh So Perper big smaller pinpoint lesions. HSP heine per which I leave to the gi talk just to go through that na I potentially always to bear in mind. Is this non blanching rash that you're saying? Is that a mimic of, say, is that a mimic of say um bruising, for example. So those are your main ones and this is from last year's talk. And Anna, I gave her brilliance to give her a shout out that it's not my side, but she certainly couldn't, I couldn't explain this any better and what we've gone through there and um just explaining your immediate management and also then your symptoms that would coincide with the history there if that's all right with everyone. Um Right now looking at the lovely viral exanthems um spot diagnosis. Does anyone want to shout that out? So I know I'm not hopefully keeping this interactive enough for you all. Um A bit of a giveaway. Maybe we given the location of this. Not a trick question. Lovely. Yes hand. Sorry Ale. Thanks for, thanks for letting me know there. So did I, so I just got to the point of this hand fucking mouth. So, um as I say, I would actually remember this almost as if you're looking at if anyone, have you ever seen Polix Eczema or the eczema that tends to affect the palms of the hands, those little quite small lesions on the hands. And then obviously in these kids on the feet, typically on the feet and on the mouth as well. So thing it goes without saying it's a fairly self-explanatory distribution of these lesions. Usually a viral illness, sorry, sorry, always a viral illness usually and almost always self-limiting after 7 to 10 days. A common theme of these viral exanthems is that you get a prodroma. So preceding the rash, the child will be very nonspecifically unwell with viral like symptoms of things like a sore throat and a fever. And really your management as you're going to be sick or tired of me saying over the next couple of slides support management, encourage your oral fluid intake, fluids by any means and analgesia pain relief as well, maybe some anti pyretic as well. Um looking at uh contact precautions as well, just hand washing, not sharing towels in the house, having separate cutlery for these kids as well and your school exclusion advice, all really good points that will really lift, I think lift your simulated patient mark and also just lift your global impression in a if the examiner can see you thinking right. He's thinking about the medical side, but he's also looking at the impact that this is going to have on kids and on parents day to day life. You know, for example, the impact on school and just life in general and things like that. So another spot diagnosis here. So that's so thanks for your question. So how long they're going to be excluded from school from? So we talk about, we talk about with good exclusion parents. The reason I brought that up at this stage is parents will often ask the same question is that how long they're excluded from school? With hand, foot and mouth disease? You actually don't need to be. But as I say, it's a common question and it's one that you need to, but you do need to tell school. So I have a slide on that coming up as well, but it's just important to raise it because otherwise parents will raise it with you. Um Looking at this one then very nonspecific big topic at the minute. Yeah. Well done measles. So again, very um similar prodromal illness, just very nonspecific, not, well, sore throat, rash fever to hand foot and mouth disease and measles. These kids tend to present with more crazy symptoms. What I mean by that is sort of a blocked nose, runny nose, maybe sunken, injected eyes. Um So things like that almost like the cold or flu would present in a, in a, in a whale person and these cop like spots then are a big differentiator in the oral mucosa, these white spots. So you have the same initial management of contact precautions. There is good exclusion with that. So it's four days after the onset of a rash. But with measles, the key thing is that and why, um, and why, um, vaccination, mmr vaccination is pushed and why it is um, warranted. And the evidence suggests it's warranted is because of the high risk of serious complications. So, with measles, you can get a really particularly nasty pneumonia, you can get this condition called subacute sclerosing panencephalitis, which unfortunately is actually a terminal diagnosis within a couple of years of diagnosis. Uh Obviously a very significant neurodegenerative disorder. It can cause blindness and then it can also cause other forms of neurological disease such as um, encephalitis, not as severe as this, but certainly obviously a very severe condition in and of itself. Um Oh, sorry, obviously as well. It's worth noting as well. Non non immune, non vaccinated pregnant contacts require a form of immunoglobulin. Um The specific ones not, it wouldn't be important to know, but just to be aware that they would be considered need to be counseled and offered that as well just as a method of maturing, they don't get it as it can be damaging to the damaging to the child as well. Another spot diagnosis again, I've just talked about pregnant women, so I've probably gave that away by, by saying that this is uh similar. Yeah. Parvovirus B 19 AK A. Does anyone know Steven Mulhern say? Would you say um, yeah, slap cheek syndrome, well done AK 1/5 disease. So Parvovirus B 19. Well done again, like a broken record. It's the same sort of viral flu like nonspecific febrile illness prior to it. So the rash appears in the cheeks, it then progresses to the body. And I think you all agree that looks a wee bit measles like in their appearance. But the um again, you'll have this preceding very characteristic butterfly sort of looking almost rash on the face and not to confuse you with lupus by saying butterfly rash, but that slap cheek rash or redness to the face. Um Usually self-limiting. The only issue is in non imune pregnant women that have, that have had their parvovirus, the serology checked, they need closer observations and just to be offered frequent reassurance scans and frequent follow up as there is a small increased risk of miscarriage by this condition called hydrops, fetalis, which is a severe form of fetal anemia that if you've maybe heard of it's a similar description of in your talk about like thalassemias and things in hematology. So, looking at moving on now to endocrine and thankfully, there are not many conditions. I'm actually only going to talk about one specific condition with this. So again, M CQ time, if anyone wants to have a go at that and just type into the chat, so I gave it away there. But yes, e and diabetic. So that's a, that's a case of diabetic ketoacidosis, uh a very severe illness. So obviously, it's a present, it's a common presentation of type one diabetes. Um, and it's, it's without wanting to labor the point. No, Craig has done a great talk on endocrine and I'm sure you have all had good teaching on it. So it's an autoimmune mediated destruction of beta cells and the Ales of Langerhans in the pancreas for anyone that still curious about physiology. Um, and AK A basically that means the body doesn't produce any insulin. Um In pes, we talk about these symptoms, the four T. So they're going to be running to the toilet, they're going to be tired, they're going to be thirsty and they're going to be thin as well. Nice and easy to remember. Hopefully. So again, it has these um which I'm not even going to attempt to talk about or describe what they are, these associations with these HLA a types of these dr three, these ones here, it's autoimmune and as a, as a, as a result, it can be associated with these other autoimmune conditions such as Celiac disease, which we've already discussed tonight. Hypo or hyperthyroidism, which just thyroid disease and also then hemochromatosis, common, slightly more common thing around these parts due to the just the nature of the genetic mutation looking in specifically at diabetic ketoacidosis. And I like to keep things fairly simple again, including the name. So diabetes and these, by the way, what's going to come up here, these are the diagnostic criteria for diagnosing DK, a really important to know these. Um, so diabetic obviously, you know, think of their blood sugars, their BM and their blood sugar is going to be over 11 and usually much higher. They're gonna be ketotic. So their ketones are gonna be greater than three and they're also gonna be acidotic and realistically that's gonna mean ap less than this. But it can also be diagnosed in the presence of a low bicarb as well. D hair, a very serious complication of type one diabetes. It's seen in approximately this is a lot more common than certainly. I thought as I was coming through medical school, it's seen in about 33% of first presentations of diabetes and uh more than half of Children with type one diabetes under three will present in this way. And it's very common right up to the early teens and it becomes less common at that stage. Um So again, sort of breaking down the physiology of it if this helps you understand it. I know in my case, this sort of thing does. But so basically, so you have no insulin. All the glucose is in the blood can't get into the cells. So then carbohydrate metabolism can take place after the body runs out of carbs. The next place it goes is fatty acids and a breakdown product of fatty acids are ketones which are acidic and that then contributes to all three tenets of this. So you have your diabetes or your hyperglycemia, you have your ketonemia, your high ketone and you also have your acid and these ketones smell like these things here, apparently, which are called power drops. Never had one. But that's what accounts for the fruity smell, off the, off the breath of these kids. It presents with all these sort of all the type one diabetes symptoms that we've talked about but acutely in DK A. So it presents with this confusion, ols breathing, which is this quite deep, rapid breathing. And the reason for that is if these people are already acidotic, one of the body's natural mechanisms for that would be to blow off CO2, which is an acidic gas. So that's what they're trying to basically big deep breath to clear the lungs of the C two and naturally buffer the the acidemia. Um They'll have a fruity smell of the breath and they can also have double vision as well. The management of this is complicated and as it says here, it's time that this is very much senior. They the main idea and you know, because it is ps it's going to be more complicated again um with volumes and things. And that's mainly due to the risk of cerebral Edem and hyponatremia in these kids by erroneous fluid management. So I always know the gist of this, learn off fig pick and be ready to recall that in an ACY and remember e and escalate early in these cases and a good, we linked that protocol down here as well. I thought this would be a good prompt to talk about pediatric fluids. It's or something that certainly can be assessed in an osk, but it's, it's complex but it is important to know. And my best advice on this is read the chart and do what it says. Keep it, it nice and simple. So some of the things to look out for in your fluid balance chart is so you want to again and say all these things in an Osk BCB pedantic? Is it the right chart? Is it for a child? Is it for the right patient? Is it yesterday's or today's charts or are you looking at the right balance to make your decision about today? Or are you going to prescribe for the right day on the backside? Look at the patient's status. So are they dry? Are they overloaded? Are they volemic? And but also interpret this in the context of your clinical assessment? Are they tolerating the oral fluids or are they nil by mouth? And what are their losses? And where are their losses coming from then? So, looking, moving on to the back then this has to be filled out in kids. So you want to get on to ACR and get their U NE, you want to wait as well. You can't do Ed's fluids without an accurate weight or well, at least a weight that has been weighed or estimated using a proper formula, but really all these kids should be weighed. Um You want to always, always impede fluids, sit, only prescribe for 12 hours and say you will reassess or get somebody to reassess at the end of 12 hours. Looking then at a bolus nice and fairly simple. Um Basically, I would say the aim of the game impedes fluids and in an AUS is be safe and don't give too much. So you can see here, there's two options. So for most things, you would say you would be body weight at times 20. But if the setting is trauma or DKA use 10, sort of for some of the reasons that we talked about there earlier. Um But I would say in an ak a wee bit like sort of like A&E if you're talking about 250 versus 500 M boluses, there's no harm in going here by 10 and reassessing if you're concerned. And this is just much like a fluid bolus in adults. It's, it's naught 0.9% saline only an important difference just for later on looking at a deficit. I am, this is complicated. So you'll see here. So part of your fluid assessment, if you have any of these, so you're using your five or 8% and just plugging into this formula here. So prescribe everything on a separate line. So your previous calculation and then this calculation will go on a separate line only use five or eight and just be careful of your rate. So you're replacing this deficit over 48 hours instead of 24. Again, just to make you aware of this. In reality, this is a fairly senior decision on this point. I would say senior pediatrician or reg would be making the final call on this with maintenance. Um You want to look at your maintenance, so volumes are fairly straightforward here. So whatever their weight is, we give four mils per kilo for their 1st 10, 2 for their 2nd 10 and one for every kilo off over 20 kg that they weigh. And uh just be careful with this here with just that you're not caught out with a big, you know, big kid or 1314 year old, 15 year old, that might be more than these weights and you don't overload them too much. So just bear that in mind. The main sentence on this here is let's consider reducing maintenance volume to two thirds. If the risk of hyponatremia is high. If you look down here at the risk of patients that are particularly at risk of hyponatremia, I would translate as most kids on a children's ward. So on the purposes of an AK I would be fluid restricted on this. I had went and revised Pete's fluids to a level that I am certainly not at. I would be on the purposes of an AUS. I would be saying I would be fluid, restricting these kids. So, whatever volume that you calculate here work out two thirds of it and that's what you prescribe. And you can always say you can reassess their fluid status and give them more. If they need it, you can give more fluids. It, it's a lot harder to take it back. A lot harder. Ak a impossible to take back out. So hopefully that wasn't too much of a whistlestop tour there. I think they're by far the most important topics. This is what zero to finals say you need to know an endocrine. Um So if you'd like to go on and have a look at that by all means, do so. But as I say, hopefully, I think I've covered what I think are the main topics in Ed's endocrine and then moving on to neonatal medicine as well, which is a minefield. But hopefully just to cover some of the salient points, I think more for M CQ land and the A KT land than an actual exam. However, you know, I know Nicole is covering jaundice on, on Wednesday. So I'll definitely tune in for that as probably one of the biggest topics of this. She's just covering that as part of G A looking at a neonatal assessment. So just to be aware of things like an Apgar score. So it's a scoring system that is performed at one minute and five minutes post birth and it's designed to predict the need for really getting the pediatrician involved in the delivery suite. I'm sure. Well, some of you may be on obs and getting at the minute, but anyone that has been out of delivery knows there's that little emergency button, for example, in the corner of the room that brings the Peds team round from the NICU. But also that if a difficult delivery or a child that was presenting with issues had known issues, you know, the Peds team would already be on site ready for the delivery if it was elective. And this helps guide that if they're not there. For example, the maximum score is 10, which is almost impossible to get actually because most kids have blue pink extremities when they're born and then they pink up after a minute or after five minutes, which is perfectly fine, but anything over seven is considered considered normal, um very clever score because the person who invented it was called Doctor Ayar, but also somehow managed to make an acronym out of it for herself. So if anyone's curious on that, which I suspect you aren't um birth and injuries, then, so really these two things, I'm sure you have seen these before, maybe been taught about them, maybe not seen them. So this is called a Kiwi or more generically a vus. And these are forceps. And really the problem with these are they can, they can be life saving in the events of a difficult delivery. They can also cause injuries such as these which are a hematoma and a caput succinum. Um And II, remember that is that this one here, the, the caput succeeds, succeeds at crossing across these suture lines. Whereas the keo hematoma gives a more pronounced bump. But that's because it's confined to the suture line here. So you can see it, it is confined to underneath the periosteum. Whereas the cappo here sits on top of that and is more edematous than actual, more edema and fluid than actual blood itself. They're usually self resolving after several months. But it's worth noting as well that ke hematoma can actually be a differential or not a cause of neonatal jaundice. Because if you imagine if you get a, you know, an injury to the arm and you have a bruise, the bruise sort of goes a bit yellow after a while, which is obviously, you know, it's a bit breakdown products of red blood cells, one of which is bilirubin, which you know, in a, in a small neonate or small baby will obviously have a much more disproportionate impact on their, on their um on their bilirubin levels in their body and potentially make them jaundiced and anemic as well. If, if they're losing red blood cells through hemolysis, another important birth and injury to be at least aware of. And if you were a counseling, a patient on a, on a, on a on an assisted vaginal delivery would be the risk of facial nerve palsy with Venus with uh sorry, with forceps. I beg your pardon. So the risk of a facial nerve palsy with forceps. And that's because as you see it, when these go on, they sort of sit around the baby's face. So it makes sense that you could have an injury when you're dealing with such fragile infants. One of the big complications that you would see in neonatology and certainly one of the ones that would be assessed is neck or necrotizing enterocolitis, which again is sort of, I say what you see in terms of his name. So necrotizing. So something's dead and enterocolitis is bowels. So that's a neonatal surgical emergency. It has a really high mortality rate, 30% and they're really unsure of the etiology or how it's caused. But it's thought to be that basically the immune system gets a wee bit overexcited by what is essentially a normal gut microbiome and all the bacteria that are meant to live healthily in the gut. Risk factors for this are prematurity and low birth weight, ie neonates, um formula feeding as well. And actually, there's a six fold decrease in neck among breastfed babies. And you know, when I was on placement in the neck, they were actually, I can remember them telling me about them using breast milk donors. And this would be one of the main reasons for it that, you know, in a, in a child for whatever reason, couldn't be breastfed, that they would get donors to use that milk instead, particularly in these babies that would be on NICU that are intrauterine growth restricted and low birth weights and premature to try and help offset this risk. And just again, sort of looking at sort of then the multifactorial issues with the neck in terms of your investigations, what you want to do. And, um in terms of bloods, you want to look for an FBC on these patients, they'll be anemic, they'll be thrombocytopenic, they'll have low platelets and they'll also have usually a high lymphocyte count funnily enough. They actually can have a low lymphocyte count. But again, they just remember deranged lymphocytes cultures are important and it's important to rule out neonatal sepsis is a differential and indeed a consequence which this can progress to the gas will show a metabolic acidosis and the U NE that that could be hyponatremic as well looking at the investigation. So radiology will come over into the nicu and do an abdominal film. And you can see here on this X ray, you can actually see regular sign. So that's where you can see the bowel wall, um also has pneumatosis intestinalis. So, er within the bowel, you can see air within the actually sometimes within the system and within the portal vein, bowel thumb printing and indeed, you could also see management, believe it or not, sometimes can be conservative. They can have a strong course of two weeks of IV antibiotics, um, made nil by mouth and fed parenterally and also then fluids and copious amounts of fluids for such a small child and inotropes as well as these patients can be septic and unwell. The main surgical correction for this would be a resection with the stoma formation. There are other procedures that they can do, but that's the main ones which is just, I still find pretty wild since a child this age, they're able to do that. It, it's amazing. And, but however, around 50% are left with long term effects. And one of those can be short bowel syndrome and like structures and adhesions and things within their abdomen from the surgery. So certainly not without its risk. But however, you know, in the grand scheme of things and certainly on account of the risk benefit of this in these cases, it would be, it's, it's unnecessary. Unfortunately, sometimes looking then at neonatal sepsis. So early onset neonatal sepsis is sepsis defined as um just that within the 1st 48 hours of life. And commonly it's spread hematogenous means through bloodstream or spread through the birthing process and you know, causative organism. I'm sure you've all heard of the length of group B strep E coli staph epidermidis or coagulase negative strep. And also listeria being the main causative organisms and GBS probably being the most well known one looking at risk factors and screening first. Then. So nice. Recommend looking if you have either one red flag or two non red flag symptoms that you start and antibiotics and investigate and work up for this neonatal sepsis. And here are your red flags. So any one of these is your goal for treating this and the two of these things here are, you know, this is sepsis until proven. Otherwise, let's treat in terms of your blood work. And what you're actually going to do is you're going to do your C RPF BPU and ES and you're going to repeat C RPS after 36 hours or even before that. And that is to do with making a decision then as to why this A is sepsis based on the trend with the C RP. Remember what I said there about you're sort of treating before you have the picture, so you can stop after 36 hours of antibiotics if the clinical picture warrants it, if you can suspect a source. So for example, cultures if you suspect a blood infection, but also then if there's another source of infection such as, you know, like eyes and wounds and things can also be swabbed to look for sources of infection. And if you suspected meningitis, these kids would need a lumbar puncture to investigate that as well. As I say, you're empirically treating this and you're going to treat it according to your local guidelines. But one regimen would be your IV, Ben Pen Gent IV and also amoxicillin can be given and that's really amoxicillin is a good cover for Listeria. One of those bugs that we talked about and really in sepsis in any kid under, you know, at a young age. And obviously you're going to consider all your supportive measures as well. Um Nearly there folks. So I, you know, if any of you saw the group chat earlier on, I hadn't initially had this prepared, so I'll take a few minutes to talk through my strategy around doing a newborn exam. Um I apologize. These slides wouldn't be, you know, these were just some slides to prepare a few minutes before the start of the talk. However, I will go on then and I will um I'll ask Nicole to cover this as well. So just before, you know, if some people are rushing off, I would just like to, I'm going to stop and screen sharing for a wee second here and I'm going to just put in the link for the feedback. Um Again, I would really appreciate some feedback. Uh If you don't mind, it just helps with our portfolio, but also more importantly how we can look at improving peers. Sure then for coming for the third years, for the future talk for third years and indeed, even for your sales coming through next year as well, so I'll do, I'll quickly run through this here. Uh This the newborn exam just to finish off. Um So really, I like to consider the newborn exam as you know, your head to toe exam, really start at the top and end at the bottom. So you're gonna measure the infant's head circumference and record that in the notes. Um and just have a look at the head. So looking for any of those careful hematomas caps that we talked about. Any other injuries, sit around the face, really important to palpate the fontanels, make sure that it's flat and make sure there's no bulging or sunken fontanels, which can be indicative of meningitis. For example. Um You're going to examine the skin for any color anomalies say they're jaundiced. Obviously jaundiced within the 1st 24 hours, always needs investigated with being pathological. Um looking for any bruising lacerations and birth marks as well, really important to document these things because unfortunately, parents have been accused of, for example, in A I when the health visitor comes out and notices a bruise and looks and says, oh, well, hang on. Well, the doctor didn't notice that when they were doing their newborn exam. So that must be new looking at the face for any features of dysmorphia. And that would be in keeping with things like Down Syndrome, other things like that that can present with facial features, George syndrome, other things, any facial asymmetry, trauma or nasal abnormalities, you want to look at the eyes for their position. If the eyes are low set, closely spaced or things like pulp or fissures. Um You want to look then and look at the pinna of the ear, then noting for any asymmetry, skin tags. And quite commonly, they have a thing called a preauricular sinus which looks like a wee hole and it seen just in front of the ears, looking down and feeling the clavicles, checking for any damage during the birthing process, looking at the upper limbs for anything, especially things like like a palsy. Um You want to check the pulses and you also want to make sure you get a pre and postductal sa so measuring the s ATS in both arms and for them BP as well. Um Also take the heart looking for any signs of any murmurs, um inspecting the chest wall and their work of breathing and they're working hard. For example, I'm sure you've all looked at the different metrics for looking at work of breathing. You want to look at the abdomen for any growth, distension, things like umbilical hernias or in particular or combination neonates any gross distension or indeed, if the stump from their umbilical cord looks particularly nasty as well. It's important to examine, especially in males to feel the genitals to see if there's any evidence of um undescended testes or hypospadias as well. Um And that's where, that's where the urethra, the urethra opens up on say the, the bottom side of the, of the of the penis, which could be um important and could cause the child's symptoms. Um And then in, in, in um girls as well, you also want to examine the genitals as well to look for things. For example, malformation of the labia, for example, in the lower limbs. Again, you're assessing the tone and movement in both of them. So you want to also make sure and feel your femorals that's really important as well and perform a barlows in order to these tests. So again, if you look those up nice and simply you can see. So with the, you're trying to either dislocate the hips or see are the hips dislocated and try and relocate them. So that's with your Barlow's test, you're pushing down and then with your Ortho lane is the one you bring the hips out to the side and then try and push back up from behind. Again, I think pictures and videos will do that more justice than I ever can here talking to it. Um And then as I said, and document all this as well. So looking at the back and the spine, so you wonder, I would run the hand down the back of the spine, just feeling the spine, seeing if there's any gross deformity or anything like that. And also looking at the back of things like scoliosis, looking in at her tough. So I'm going to, you know, you will be glad to hear this is the last question that I'm going to look at. So I have one condition in my head. Does anyone know a condition that can present with a tuft of her at the base of the spine? Yeah. Brilliant spina bifida. So it could be a meningocele or a myelomeningocele and causing them not talk to her. You want to look at the, look at the child and make sure there's the in patent. So what I mean by that is you can have this condition called an imperf iness where it actually doesn't open out then and obviously, that would need rectified very quickly. And then finally, just to do your mal reflex especially. So that's the one that and if you're doing it in front of the parents, you warn them so that they're not accusing you of trying to drop their child. So it's the one where it should be present where you hold the child and then just sort of drop the child down onto the other hand or lower the hand very quickly. And then you should get that reflex, throw the hands back to put it simply. And again, I would just look at a video and things like that. So a week quick run through there. Um, again, I think looking and just as I said in a message, I don't think it's probably the most likely thing to come up, but it certainly could come up. So just bear it in mind and um, I would still practice and just have that if you have that head to toe exam, if you're systematic and you're logical about it, then work you away from the top down and you won't go too far wrong. So just some general pages tips. So looking in our Aussies, remember the BF GD? Every history, birth feeing, growth and development be nosy. Um And ask loads of questions. Are they vaccinated? Are they developing? Well, any concerns, how were they born? In some cases? It may be important to know if they're naturally, you know, if it was a natural conception or IVF, for example, um Are they plotting along their centiles? Any growth concerns? Things like that always clarify who is with the child. So if there's two people there don't assume their mum and dad don't assume their mummy and granny, don't assume their granny and grandad always clarify who they are and their relation to the child, especially important in things like genetics. If you're counseling for a genetic condition, obviously, very important if you're examining or counseling a child. And I know this is difficult to say in the stress of an oy. But try, don't use big words obviously, but also try and make a wee bit of small talk. Like if they have a, if they have a football jersey on, you know, ask them about the football or ask them who their favorite superhero is or who their favorite pa pa control character is things like that, you know, really communication skills, that would be excellent there if you could do that. And it would mark you very highly. Certainly in my age, if I was examining it, um, inquire about and do not dismiss parental concerns ever with kids, it actually even scores it much like on a news chart and Aug chart, which is the pediatric version actually has and scores points if the mum and dads are guardians say they're concerned. So do not dismiss them and learn your common guidelines for the asthma guidelines for kids, which I'm sure Nicole will cover. But also things like the nice pediatric red flags. And if you Google that basically your red flags or things like a high respiratory rate, rashes increased work of breathing all those things. So again, have those learned off and some useful resources then. So I would say these are the two books, these are the two books I used um this one here, this Laar textbook, you wouldn't necessarily be going out and spending money on that, but they are available in the libraries. And I think they're a good resource in that sense. You know, it just adds a wee bit more extra, but this should be, this should be your main resource here. This is the finals, pediatrics, the finals are excellent, all their books. So definitely, I would know the majority of that inside out and then you're teaching me pediatrics, which is actually only website I learned fairly regularly or fairly recently. Sorry. And teach me surgery is a, is a more common one but the same website, same sort of website and same good level of resources. This is quite for interest. This is quite a funny book I'm reading. There's some funny tales on it so that I'm reading at the moment. He's a pediatric anesthetist in Dublin. I think he's actually done a talk with one of the societies recently, but good read. If you're interested, he's a pediatric cardiothoracic anesthetist. Just if you want to become really subspecialized in your life, that's his choice, but quite funny as well. And finally, I think it helps if you've done a page rotation, you probably realize that knowing a little bit about these two things can go a long way in, in getting a child on side as well. So, folks, that's everything, any questions, I'm more than happy to answer them by email by now or at any stage. And I suppose all's left for me to say is thanks for coming and best of luck in the exams and things coming up. I'm sure you'll all do. Fantastic. And finally, final plug some feedback would be great, please. So, if you could fill that link in now, I'd be very grateful. So happy to take questions for a few minutes. Thank you. No bother. Thanks. Thank you. Oh, about it. Um Folks, I'm gonna head I just need to head on here. So anyone that's still on the call, just if you have any questions with the email will be on those slides. So feel free to drop me a message. Alright, thanks.