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Stands for birth. Um and then birth related to both the pregnancy um of um of the mother of the patient and also um uh their birth history. So during and after birth. So when it comes, when it comes to pregnancy, you can ask about their scans. So whether they had any uh they, they had their conventional dating scan at about 10 to 13 weeks. Uh and then whether they had their anomaly scan at 2018 to 20 weeks, um just look for any abnormalities. And then also did they have any extra scans? And if they have, you know, what were they for? Because that might uh indicate some, some not abnormal pathology going on uh with either the mother or the uh or the growing fetus. And uh that's why extra scans were needed and then also complications. So this could be maternal or fetal complications. So maternal, you can ask, but they were, they were, they're ill because they could have had group B strep. Uh they could have, you know, been um IV drug users or, you know, they could have smoked in their pregnancy, which may have, could have affected the, the child as well and then um uh of the, of the child or sorry, the neonate. Um you can also ask about, you know, whether, whether they were ill after, after they were born, did they have to stay in um in an intensive care unit? Um for example, if they're premature, they usually have to stay a couple of days to a week um depending on her premature they are. Um and you know, did they have any other medical problems when they were born with the, you know, jaundiced, the natal John, this is a very, very um important um important diagnosis and requires urgent treatment. Um So those are the kinds of questions you can ask. Uh and in terms of birth history, so you can ask about how, how they were, how they were born. So either is it why a normal vaginal delivery, is it via C section or did they use instrumentation like forceps delivery? Um And that's kind of important, especially in the neonatal stages, you can if, if a child comes with bruising on their head. Um And that, that's usually um you due to the use of forceps because of the pressure. Uh and then you can also about gestation. So uh were they born at term and term is usually between 30 to 42 weeks? Uh And then if it's less than 38 it's suggest prematurity. Um and then you can also ask about birth weight. Um So a normal birth weight would be between 2.5 and 4.5 kg. And then also, as I mentioned, um the maternal fetal complications um this is to be after birth. Um uh you know, did, did the, did the mother have any, you know, like placental abruption uh previa uh and then fetal complications, things in your jaundice, as I mentioned earlier. And then um f in the B F G D acronym is for feeding. Uh So this is very, very broad. But briefly, I think the important thing to know is always compare normal versus abnormal feeding. So how is that, what did they usually eat? What kind of diet do they have before? And how has that changed after they're presenting complaint or the illness, etcetera, it's always good to establish normal. Um and then um looking at how it's changed and then also type. So depending on the age. So if it's less than six months, uh infants are usually breastfed. Um if not, they've given formula milk and then after six months onwards, they start to be weaned off breast milk or formula milk onto mashed up or period foods. And then um usually around 12 months onwards, they moved on to solid foods. Okay, you can establish where they are at this moment. And did they have any changes? Like for example, um if they, let's say they were um uh breast fed and then they were switched on to formula milk and ask them why. Um And sometimes, you know, let's say they were on formula milk and they were suddenly switched onto, you know, specialized formula milk like hydrolyzed, um extensive hide rised milk. And that might be because there's something like cow's milk protein allergy. Uh So how's milk protein in formula milk can cause them to have symptoms like diarrhea? That's, it's a very good question to ask as well if, if you notice something like that in the history and then also volume and frequency, how much do they consume? How often a day? Uh And then going along with that is asking about their bowel motions as well, which is what comes in the toilet inhabits. So how often, how often, um do they have a wet nappy? Um And that's just to ask how the urinary frequency is and typically it's about five times a day for an infant. Um And then the bowel motions will be about three times a day and it will be usually yellow colored healthy stool and then also toilet training, which is for an older child. Toilet training usually starts from 2 to 4. Um And then g stands for growth. Um So this is uh this is very important, especially when it comes to assessing a child's health because, um, you know, uh quite different to adults, you know, children's have a rapid, you know, weight gain weight and height or increase in their weight and height as they're growing, it's a period of rapid growth. So it's important to monitor that. And that's typically done using the red book. So you can always ask to see their red book as well because the red book measures height and weight, um as, as the child ages. Um and to make sure that it's, it's going in the right track. But if there are any concerns, um if they're, if they're, if the growth is tapering off, then you'd want to be concerned about it. Um And then, you know, you, you, you have to wonder, is it something like failure to thrive? Um And I haven't really talked about in this lecture but failure to thrive. It's basically when, when you're not growing well enough or at the expected rate um uh compared to someone of that age. Um and there are so many different causes, could be cardiac, you know, Children born with congenital heart disease like ventricular septal defects, they can get things like heart failure that can lead to their growth being affected and, you know, respiratory conditions like, you know, if they have recurrent infections, um they can also that can affect their growth. Um and malabsorption um syndromes like um cystic fibrosis where you don't get enough nutrition being absorbed through the gut. Um because of lack of um you know, pancreatic enzymes and things like that, there's also metabolic diseases where you don't have enough enzymes. Uh And since I'm deficiency and all of these can cause um uh the child not to grow. Okay. So it's very important to ask about the red book. And in addition, it has things like vaccination history as well. Uh And if it's an older, older child, especially and adolescent, do you want to, you want to ask how their, how their puberty has been going as well? So for a girl that would be after 11 years of age, for a, for a boy will be after 12 years. And then finally d which is for development to um of the child. So the main important thing is to ask whether they're, they've been meeting the development milestones and usually um parents can keep track of it um in the red book. Um And I think, yeah, and if have there been any concerns, have they not had a, have they not developed or have they not had any development milestones being met? Um And any, any red flags things like that? And something that would be, you know, very advantages is if you can remember a few significant milestones that they should have, should have developed across um at a certain age, for example, you know, they should, they should be able to um walk by themselves by 18 to 24 months. Um And then your speech by 18 months and things like that just to show the examiner, they were like your depth of knowledge. And especially if the, if the child is, let's say of, of a certain age, you can ask, you know, have they, have they started walking yet on their own, you know, how can they sit up by themselves and things like that? Just to show that you're thinking um, very broadly okay. And then, um similar to, you know, um normal, normal history, you would, you want to ask about their past medical history, uh surgery or any, any medical conditions and also previous hospitalizations. This is very important because things like recurrent infections, uh might, you know, point towards um, something either that might, they might be immunocompromised. Um And so if you like um, conditions like, um, cystic fibrosis, um, gas risk of a jewel reflux disease can cause you to have infections as well. It's good to ask whether there, you know, but they've been in hospital more than one time, more than once and then drug history. Always important to ask about immunizations because a lot of conditions can manifest because of, uh, not because the child has not had all the immunizations. And it's also good to kind of have a rough idea of the immunization um schedule as well. Um It's, it's, it's a, it's a comprehensive lift, but if you remember some key points, it would be very advantageous in terms of medications. Are they currently on any medications? Have they been previously on any medications? And you can also ask about the dose, uh frequency and the route as well. And most importantly, in all histories, it's important to ask about drug and food allergies, especially food allergies. Um, you know, things like peanut allergies and things like that is very important in a, in a patient who comes with acute shortness of breath because that could be due to anaphylaxis. That's the important question to ask in terms of family history. Um, you know, asking about any relevant medical conditions in the family and also asking whether any other members of the family are also sick. And this is more important um in, in um in infants and younger Children because they may have older siblings were also sick, so they might have got gotten sick from them. Um And then finally, finally, sorry, social history as well. Um I'll ask you about who lives at home and does anyone in the family smoke as well? That's very important, especially um if you want to establish um whether this patient might have asthma because household smoking can, can be, can be uh respected for that and also the housing situation where they live. And also finally, this is very important is always making sure to ask whether there are any, there have been any safeguarding concerns of social services because it's very important to recognize these. Um and especially in a station where a child comes in with bruising, it's a very important question to ask because you don't want to um you don't wanna miss out a nonaccidental injury. Okay. So, for them to be on the safe side, I think it's just one question definitely worth asking, uh, in your history. Okay. And then finally, ideas concerns expectations, you know, do you have any idea what might be going on? What are you worried about and what do you hope to get out of coming in today? And finally, I think something relevant to pediatric is, um, has it stopped them from attending school? If so, that might suggest the severity of it? Okay. And then, you know, um similar to or histories systems review and this system review should be tailored according to the presenting complaint. For example, generally, if they're coming in with a fever, you should definitely ask them about activity levels and rash is very important, especially in things like manager cocoa septicemia, um and then their growth and weight. So, you know, uh depends on, you know, their food intake um and things like that um due to the sickness um that might, that might have decreased. So they might not be growing as well, especially if it's been a, been a long term illness. And then you have cardio respiratory uh you know, things like cough um and then establishing whether it's dry or wet cough and the noisy breathing. There's there's so many different types of noisy breathing. So the most common ones are Inspiratory Stridor, which is seen in conditions like bronch uh group. Um and epiglottitis because it's because of upper airway narrowing and it's noticeable when you breathe in. So it's inspiratory Stridor and then there's also Xperia Tory Wheeze, which is, you know, most commonly known for, um, uh, asthma. Um, and then, you know, um, crackles which are usually heard on a mosque quotation but, you know, sometimes they can be heard, um, if it's, it's, if it's particularly, um, severe, severe pneumonia and things like that, you want to ask about shortness of breath and cyanosis as well. And cyanosis would be um indicative of um severe respiratory compromise. And then there's g g eye as well. So warm eating when it, when it comes to war, meeting, the most important thing to establish is whether it's bilious or non bilious. Um And I'll talk a bit more about that later on. Um, and also whether there's any blood in it. Um, and things like that and also accompanying it. Is there any abdominal pain? So if it's, if it's a child that can talk, it's always good to ask about abdominal pain and also change in bowel habit, either an increase in frequency, is it diarrhea or a decrease in frequency to do something like constipation? And then also, you know, there are different other, other systems as well. Genital urinary, neuro muscular and ent. Um and I won't, I won't go too much into this, but I think something worth remembering is, um, let's say, um, child that comes in with a suspected seizure and abnormal movement of their limbs. Um You definitely want to ask um whether they've had a fever because the federal federal convulsions or febrile seizure is one of the, one of the biggest causes or high temperature. Um is uh is one of the biggest cause of seizures. And it's definitely not to be missed because if the fever is not treated promptly, it can cause severe neurological dysfunction as a consequence. So that's definitely um worth remembering. Uh And in ent uh just few things like sore throat, earache, which may eric might be due to titus media, external things like that. Um And they engender urinary, always important to ask about um wet nappies. So they urinary habits. Um and then um I've just briefly uh put it in a table and I won't go and go through all of this for, for time's sake. But I just just want to reiterate. It's, it'll be good if you know, I know a few uh few milestones according to the different age and I just highlighted them in yellow. Um something worth remembering like, you know, they should be sitting alone by 99 months. Um If they're not sitting alone by 12 months, that might be a red flag, okay, should be walking alone at 18 months, holding the objects um in their palms, okay. Uh And then smiling by six weeks and then, you know, speaking um coherent words by 18 months. Um, and you know, those kinds of things. Um, and then I've just listed a few here as well. If you, if you can demonstrate to your, to your examiner that, you know, these kind of things, I'll, you know, take you up to like an excellent student kind of thing, but it is a comprehensive list. So you don't have to remember everything. If you can remember a few things will be very helpful. And then I've also briefly uh made a table of the immunization schedule as well. Um Just a few, few things to remember here as well. I think 11 thing I definitely point out to is knowing when the Mmr vaccine is because, you know, missiles bombs and rubella, very important presenting can be important, presenting complaints, sorry, it could be important diagnoses uh in, in, in a child presenting with fever rash, things like that. Um And then remember that it's taken at one year and around three years when they're starting preschool, there's also HPV vaccines is more gynaecology related but um to prevent things like cervical cancer and all the all the related cancers. Um And then I think another one is the meningitis vaccine as well. So you got the meningitis B um which has about four doses. And then um adolescents also get the meningitis A C W Y and this is usually before they head off to university or, you know, before they around when they turn 18 and that's because of, um, to prevent meningitis, which is when it's one of the biggest causes of morbidity and mortality. So, those vaccines are very important, which is why it's very important in the history to ask whether they've been up to date with their immunizations. Okay. Right. So some key points to remember when you're taking a pediatric history, I'll just very quickly gloss over this. Um, if there are any changes to diet, make sure to establish what the normal pattern is in terms of frequency, what kind of food, um what kind of food they eat? Um And um whether they've noticed anything different um from their previous pattern to now ask about immunizations and development milestones, know a few red flags if you can and asked to see a red book. And this is very important, especially if a child is coming in with failure to tribes, you know, growing um growing um uh according to some one of their own age. Uh and then asking about safeguarding concerns or social service involvement, very important, especially in a child that comes in with bruising and Conductor Systems Review, relevant to presenting complaints. For example, as I previously mentioned, they're coming with a cough, ask about shortness of breath, ask about any cyanosis um and things like that. Okay. So uh let's, let's um go through the first case. I'm just gonna quickly open up the chat before we go on. Brilliant. Um uh Yes, that is, that is very true. Now, recently they've started offering the HPV vaccine to um boys of um, that age as well. So, um, so our first case is a, is a eight month year old whose comes in who comes into the pa you with a cough? Okay? And then you'll take a cholesterol history um from the mother. So I'll give you guys about 10 to 20 seconds. Um Can you guys think of what um some questions that might be worth asking in the, in terms of um exploring the history of presenting complaint, what would you want to ask someone coming with a cough? Yep. Yep. So timing is very important. Yep. How long have, have they have it for fever? Yeah. Systems reviews important. Productive. Yep. Yep. But it's a dry or wet cost. Um Yep. Choking. That's also a very good one to consider as well. Cries or worse. Mhm. Yep. I'm seeing really, really good answers. Yeah, that's perfect. So just in the interest of time, I'll just um just talk you guys through it. Okay. So you guys said very, very good answers. Um And you guys are really thinking of exploring it really well. Um So I won't really gloss over, you know, the typical things you ask in a cough history, but I'll just focus on what additional stuff. So you talked about, you know, the duration onset timing and things like that, okay? But when it comes to, um, timing. I think it's very important to ask whether it's, um, uh, worse at certain point, uh, certain points during the day, like, for example, in the night. So if, if it's a more prominent nocturnal cough, that might be indicative of something like asthma because that's one of the prominent features. Okay. Uh, and then where they keep them up at night, especially in, in an acute cough. If it's keeping them at night, it's making them cry a lot more at night. Uh That might indicate that it's quite severe and would uh would be would be a prompt for them to have an urgent, urgent assessment. Okay. And you guys mentioned whether, you know, whether it's productive or, or a dry cough, if it is productive, what color is it? Is it green in color? That might be, you know, indicative of prevalent um sputum which might indicate infection for the pneumonia. But other than that, you know, is there any blood in it? Yeah, that would be you want to be concerned um that also might indicate very severe pneumonia as well. Um And I guess it's less, less likely to be a malignancy in, in a, in a child, but, you know, something worth remembering as well. Uh And also asking about how, how much is it, how many um um spoonful of sputum are they bringing up? Okay. Um And then in the systems review, I think you guys mentioned a wide range of um things to explore, which is brilliant. But, you know, I just want to reiterate that it's always very important and I'm sure you guys know this already. It's always good to start off with an open question and then moving on to a very closed focused questions. Uh So for example, in the system, you can ask, did you notice anything else? So prompt the, the, the patient or their mother or a parent to give a few answers, which, which, which shows that, you know, you want to, you want to see what they say and then um kind of go into more specific questions to explore. Are there any other other symptoms or signs they've noticed? Right. So, as I mentioned in a, in a cough, you should talk about anything other, other respiratory ated. Uh for example, have their in shortness of breath, any noisy breathing. Um um you know, like strider or wheeze, um did they go blue at all? So, is there any, any cyanosis and that might indicate a severe disease as well? Um And then you can uh you know, if it's, if you suspect it's an infection, you don't ask things like fever, whether they've had any fever and uh any vomiting as well. Um This is very important because um you know, some, some gastrointestinal conditions like I mentioned earlier, like um gastrace of with your reflux disease, you can, you know, you, you warm it quite a bit. And what you can get is aspiration pneumonia, which is when the contents of the stomach can go into, into your, into your lungs and cause, um, um, pneumonia and also things like cystic fibrosis can also cause you, um, recurrent recurrent chest infections as well. Uh, so it's always good to, um, ask about vomiting and also drooling. Um, do you guys know why it's, why would, but it be an important question to ask, not typically really asked in, in a cough history, but in a pediatric cough history, it might be perfect. Hepatitis. Yeah. Um one of the classic simple uh sciences that they have a lot of drooling of saliva. Um And so it's important to explore as well and it shows that, you know, if you explore the different, different um uh symptoms, it shows the examiner that you're, you're thinking about a wide range of differentials. Okay, then let's move on to, you know, the rest of the history, uh you know, past medical history I mentioned before, I won't, I won't focus on this, but just, you know, may be worth asking whether this happened before. Uh And, but, you know, I've mentioned um uh the thing, uh the important questions to ask, I won't really go, go through them again. But I think an important thing is, did they stay in hospital after is, but after the, after the child's birth because that might indicate, you know, things like prematurity or they may have a complication like neonatal jaundice um and things like that, which may point towards going towards a diagnosis. Um And then also feeding, um it's very important to ask about their diet frequency volume and whether it's changed as well. Um And, you know, comparing normal verses um how it's changed. Uh And also the uh as I mentioned, the frequency is very important because usually, um you know, if a child is unwell that, that the appetite decreases, um, and then often, you know, they feed less frequently as well. Uh And that might indicate a bit more, you know, a bit more severe disease and therefore that, that might, sure that they need, they might need to be admitted uh to give things like fluids, um, and other, other medications, uh, and asking about the urinary habits as well. How many wet nappies and whether it's changed and then growth and development asking about their development milestones and read book too, just to measure their, measure their height and weight. Uh, sorry, uh to see the changes to their height and weight and then last couple of bits which is, you know, I mentioned family history. It's very important to ask about whether any, any of the other siblings and well too. Uh, and in terms of drug history, um, immunizations are a priority and drug allergies and in the social history. Um, uh I just saw a question now at what age do you stop asking them. So the red book is usually from birth to five years of age. So after that, the red book won't be used anymore. Um in terms of social history, um it's important, um, you know, ask about smoking, parental smoking, very important one of the risk factors for asthma and also any pets at home, you know, that might also be a trigger for asthma and importantly, social services and safeguarding concerns. Okay. Um And then I see. Can um yeah, I ask about any concerns or ideas of what might be going on, right? So, um so and then when you, when you come to summarizing the history, it's very important to incorporate especially B F G D. So the birth feeding growth and development into it as well and making sure it's as concise as possible. It is a bit long than the conventional history, but it's important to show the examiner that you have included that in your uh when you're presenting it back to them. Okay. So let's take a look at um at what this patient has present the story behind this patient. So nine month old Jack um has had a dry cough for the last two days and also had a fever of 38.2 degrees and also has been chorizo. Um they're not been playing or drinking like usual, has not had many wet nappies either uh and is currently consuming, mashed up food, but his appetite has significantly reduced. So you can see he's mentioned what their normal diet is uh and how it's changed. Okay. Um It is very important. Um And then it's always important to um mention relevant negatives as well, especially talking about blood. Uh So there's no uh blood in um in the cough, sorry, I meant no blood in the sputum. Uh and there are no rashes, no fits and um no cyanosis and fits is very important, especially if someone's coming to the fever, like I mentioned. Uh and rash is also the same. Um You want to be cautious of that in someone coming to the fever and then relevant um relevant other things to look forward. Um So they have not had any previous medical conditions, surgeries or hospitalizations. Uh There's a family history of asthma. Uh He's not on a medication, but he was given Kalpoe to reduce the fever, no known drug allergies. Always good to mention that uh lives at home and then with his parents and his older sister who is well in herself. So it's sure, you know, it's good to show that, you know, you you asked about the siblings. Uh and there's some parental smoking going on. Um and he was born without any complications via normal um vaginal delivery and he's up today with all his vaccines and um meeting his milestones. Uh mother is worried about the health um son and has no idea what might be going on. So given this information, what, what do you guys think is the top differential here? Can you put it on the chat? Yeah, perfect. Yeah. Right. You guys definitely got it. And can you think of any other differentials for this? Um So yeah, so the top differential here would be crude because of the, you know, the seal like um cough and it's dry. Um and he's been Kreisel and it fits into the, the age range, um, as well. Uh Yeah, I'm seeing. Yep, bronculitis. Perfect. Yep. Yep. Whooping cough. That, that's also a good one. Any anything else? Yeah, pneumonia's perfect. Any, any cause of, um, kind of an acute, um, cough, anything else? Uh Yeah, I'm getting, yeah, uh, foreign body aspiration as well. Yeah, it could be, could be lower, lower down the list because that would be very, very acute. Um, and be a bit of a different story. Um, while induced we is perfect. Yep, that's also a good, good differential. Um, and cystic fibrosis. Perfect. Um, yeah, even 65 is a good one. Um, but it's lower down because, you know, you get things like steatorrhea. Uh um and uh, you know, more fairly to thrive and things like that, but I think bronculitis is a very, very good um, differential. Uh And then another thing you could possibly think of especially with the fever is acute epiglottitis. Um, but pneumonias should definitely be there upon the up on the list as well because it's one of the most common conditions. Um infective conditions in Children under the age of five. Yeah. So uh I've got a few spot diagnosis for you. So I'll give you guys a few seconds um to read this and then kind of to put it on the chat. It's kind of exploring what we talked about before. What do you think this child is presenting it? Yep. Perfect bronchiolitis. Yeah. So in 80% of patient's, it's usually respiratory sensitive sensitive virus RSV that cause it. Um and it has a very similar presentation to um the group but however, that the cough is um it's not, it's not like it's not a very uh loud shop. Um see like a barking cough like in group. Um but it's quite similar uh and then move on to the next one in the interest of time. So a six year old child is brought with acute shortness of breath and nocturnal cough. Family history is significant. Yep. Perfect. Yep. So patient is coming with a nocturnal cough, which I mentioned earlier on and they also have signs of entropy most likely going to be an acute asthma. And then the next one. Yeah, it would be acute exacerbation of expert. Perfect. Yeah. Brilliant. Perfect. So green sputum um fever, shortness of breath. Um And what's the, what's the significance of the chorizo or the fact that they have been Coryza for a couple of days? Anyone? Mhm. Someone said, yeah, back to your PSA bone infection. Perfect. Uh Yep. Yep. Yep. So they most likely had a viral infection, you know, which kind of dropped their immunity. Um And as a result they got a secondary bacterial infection or um um Yeah, perfect. Um And then the final one we talked about this earlier on. Yeah. Perfect. Perfect. Um Can you guys answer um why, why, why do, why do, why do they typically present with drooling? Why is that a particularly uh striking feature of patient with hepatitis? Yeah, perfect. Yeah, you, yeah, because of um dysphasia. So it's very difficult for them to swallow because of the pain. Therefore, um the saliva just builds up and then they um um yeah, they drew. Um and this is a classic picture which is one of the most important signs, which is called the tripod sign, tripod sign, a position or sign, uh which is where they are kind of leaning forwards. Um And they've got their neck extended that's just to open up the airways and you know, make it expand because one of the one of the features is severe airway obstruction, especially upper airway, the epic noticed and as a result by staying in this position, they can, they're a bit more comfortable and can breathe. So it's very important that you mentioned, especially in a patient with a particular tightest uh in their conservative management to make sure that they're comfortable at rest, make sure they're not lying on their back. Um, and if they are happy to be in the tripod position, just let them be because that will ensure at least a sufficient, sufficient ventilation, uh, sufficient ventilation will happen. Right. Ok. So when it comes to pediatric cough, you can split to acute or chronic. Okay. And I've, I've explored a few of the acute ones which I won't go into much detail, but a foreign body which, which as I mentioned can be a possible differential, uh, less likely in this case because you'll be acute. Um, and it would just be, you know, a matter of hours. Um And he's really, you know, the classic stories that, you know, a child that's been playing with small objects or toys. Um, and then, um, usually it's a witnessed event as well. Um, and then, um, yeah, I mentioned pneumonia and things like that, uh, in terms of chronic, uh, you know, I talked about cystic fibrosis. Um, another question that's worth asking in someone come in, the pediatric cough is the bowel habits as well. Um, asking whether, especially about the stool, uh, you know, whether it's, it's got a foul smell, whether it floats um in the toilet because that might indicate steatorrhea. Um And then, you know, if they have failure to thrive and things like that because of the malabsorption, um, and as a result, um, they can, yes, they can get cystic cough it's cystic fibrosis and that's mostly due to those recurrent infections that they get. Um, so they, because if, um, they're more likely to kind of aspirate and things like that, um, because of that, they are more likely for aspiration pneumonia and with that, you can get a cough. So it's not directly because of the cystic fibrosis, but it is, um, as, as, as, as a consequence of that disease. And then we've talked about asthma can be acute or chronic. The important thing is, um and this is something um I learned in my pediatric block is um usually to confirm the diagnosis of asthma and a child, they have to be five years and above. Uh So it's important that if a child under that age comes in, it's very um I wouldn't advise saying asthma as a, as a differential diagnosis because you can't, you can't confirm the diagnosis until you're of a certain age, which is five years old. Okay. And then I've mentioned in reflux because of aspiration pneumonia. And then you got, you know, things like primary serially uh diskinesia, which is a bit more of a rare condition. Basically, your silly aren't working. Therefore, you get mucous build up because um you Quincy isn't cleared away and things are bacteria and pathogens can, can develop uh and they can get infection that causing um uh cough and then things like alpha one antitrypsin deficiency. So usually, you know, it's one of the genetic genetic abnormalities that can cause COPD. Uh, and especially it's a patient, a young patient or, you know, a teenager comes in with speeches of obstructive permanent disease you might want to look into for one antitrypsin deficiency about businesses. It's a bit more rare and less, less common, but I think acute cases of cough are definitely worth knowing. Right. Um, so in terms of, uh, I think in the interest of time, I'll just go through the investigations. Okay. Eight, we always important if it's an acutely unwell patient, okay, basic observations especially pass oximetry to measure oxygen and temperature because you, you want, you want to check whether they have a fever to give antipyretics and then pass oximetry oxygen. Um in case you want to give supplemental oxygen, if they're, you know, particularly respiratory, uh if they have respiratory compromise, rest examination, uh just to confirm any, any pathology you're looking for, if you suspect they have asthma for signs of expiatory wheeze uh even environment used to use to check that. Uh and then peak flow measurement. Um this is this is to just kind of help with the diagnosis of asthma. Um looking how quickly um you can can empty your lungs aware. And if there's, if there's, if it's reduced, that might suggest obstructive lung disease like asthma. And then if, if a patient comes in with a productive cough, you want to do a sputum culture and identify the causative organisms so that microbiology can give targeted um antibiotics and then very important I think, especially because one of the biggest causes of pediatric cough is are things like bronchiolitis and group. Uh So it's very important to suggest doing a bedside waddle nasal swap to look for their positive agent. Um It's, it's not really required for the treatment because the, because the diagnosis for group and bronchiolitis are, it's a clinical diagnosis according to their symptoms. Uh And it is not particularly um needed for their treatment, but it's something you could suggest. Uh and just to just to confirm the etiology of it. Uh and then bloods, you know, doing your F B CS to look for an infection. You, Susan is very important, especially in Children presenting. We think the bronchiolitis croup because they can be dehydrated because, you know, they're feeding an oral intake is probably reduced because they're unwell. So you want to definitely check for any, any signs of raised urea and you also get, you know, with dehydration, um you can get electrolyte abnormalities with that as well and then a capillary blood gas. So conventionally, in adults, you do an arterial blood gas or a venous blood gas. But in Children, because of the small stature, you do what's called a capillary blood gas, which is, which is, which is less painful, especially important for neonatal and um infants. Uh And this is to look for any, you know, disturbances in in respiratory or you know, metabolic status. So for example, you know, if, if let's say the child is hyperventilating, um you know, there to keep Nique, um you know, they might be throwing off their CO2 very fast and as a result, their PH can drop and they can um develop a respiratory sorry, the PH can increase, developing a respiratory Oculus iss. Uh and then if you suspect the infection, you know, you could consider doing blood cultures, especially if it's spread to the uh systemically. Uh and there's sepsis and the CRP just to, you know, look, look for any, any signs of inflammation due to infection chest actually very important. And this is like if you suspect pneumonia and things like that, but it's also important in patient's presenting with viral causes because you want to rule out any, any. Um so you want to rule out pneumonia uh and to make sure that it is in, it's in itself a viral etiology. Uh and also very important when it comes to visualizing a foreign body. So for extraction and things like that, it's very important. Uh And then, you know, some special tests, not very important. The first to sweat test, you know, looking for raised chloride, suspect cystic fibrosis. Uh and there's something called immune if or essence of nephew geo secretions. Um and then if that's positive, that's, that's also a sign used to identify respiratory syncytial virus in bronculitis. Uh but two important ones, especially after Charles, the age of five um is using uh for the diagnosis of asthma. You can use these two tests, uh spyrometry with bronchodilator reversibility testing and then the fraction of exhale nitric oxide. So, spyrometry, you know, you check the TV even over FEC ratio, okay. And if it's less than 70% that would typically indicate an obstructive cause like asthma, okay. And you do something called bronchodilator reversibility. So what you do is um so you give them um salbutamol and then you try to look for an um improvement in their spyrometry and if it's reversed, if their spyrometry improves, um that shows that, you know, it's most likely you could be due to asthma, okay. But however, if the, if the spyrometry is inconclusive, you can go on to do something like faction of exhale nitric oxide and there's the usual cut off if it's later than uh sorry, if it's greater than 35 parts per billion, I believe that is most likely indicative as, as much, but you do always want other things to help out like features of A two P. Um and things like that. Um usually uh in terms of doing spyrometry from, from my understanding, um it's usually Children that can, you know, follow instructions. Um um and um you wouldn't really do it on a, on a new unit, which is why, you know, you would wait till they're five years of age to confirm the diagnosis as opposed to doing it, doing it earlier. Okay. Um So um so this is a, so that's interest of time. I won't um, ask you to um, ask you how you would interpret this chest X ray. But can you guys please put on the chat? What do you think the, is there any abnormality in the chest X ray? Yep. Yep. Okay. No. Mhm. Anyone, anyone in the neck? Okay. Any, any, any abnormalities that you can see? Yeah, perfect. There we go. Um steeple sign. Exactly. Okay. So I won't, I won't go through how to interpret a check structure. I'm sure you guys are already familiar with it. Um which is something worth pointing out. You can only check for things like cardiomegaly on a P H S directory. Um um but this in itself is um of a, of a child with group because um and also make sure to mention that it's a P H S structure as well when you're interpreting. Uh But I don't know if you can appreciate at the top here, the trachea here, there's um supraglottic narrowing, sorry, subglottic narrowing. Um which is uh it's like an inverted V ship. It's also called that um sorry. Um And this is one of the one of the typical indicators of um group um and it's classically seen. Um And that indicates that, you know, just further, like, demonstrates how, you know, how restricting it is um of ventilation, which is why it's important, especially I think this is one of the features that are seen in moderate, moderate to severe group, which is why you need prompt treatment. Um using, you know, steroids and even, even things like nebulized, so beautiful and things like that. Okay. Um So yes, stable sign is this this um subglottic tricky, we'll narrow into the trachea that's narrowed. Um And it's indicative group. Okay. So, um so how would you, how do you manage group? What would be some key things to remember when it comes to management of group? Can you guys list them on the chat for me? Yep, dexamethasone. Perfect. Perfect. You guys know how much dexamethasone you would give. Mhm. Yep. I think I saw it somewhere. Yeah, 0.15 mg per kilogram. Okay. Um And you would um um so basically, you know, split a conservative medical surgical, conservative educating the patient family and one very important thing is making sure the patient is as comfortable as possible because remember that their airways are narrowed. So if you get them worked up, the work of breathing increases and um they can get very, you know, out of breath and tired. Um if they can meat, the meat, the oxygen demand, okay. So making sure they're not agitated, that's very important as well. And something that would be, you know, that was sure that you're thinking a bit outside the box as well, not just thinking about the medical things uh and also um safety getting the patient. Um if, if let's say if it's a small group, um they can typically be managed outpatient, but if they do develop severe symptoms, they need to come in as soon as possible. Okay. Um So um they need to be admitted to hospital if they have moderate to severe group. Okay. And this, this severe group features could be, you know, they could be technique. And you remember remember that in pediatric respiratory rates and heart rates are significantly great uh in terms of ranges compared to adults. So in, in uh what's considered tachypnea in a, in a child is usually greater than 70 breaths per minute. Uh I think that an tachycardia, let's say they have decreased level of consciousness. Um that can, that can also be a factor. Um that indicates that, you know, they are they are they having severe group there cyanotic. Um which is why it's very important to admit these patient's and then give them um supportive treatment, you know, high flow oxygen. Um if the oxygen saturations are less than 94% or they have either type one or type two respiratory failure. Um and then you have, regardless of the severity of group, you definitely have to give them dexamethasone orally if they can't, um you can give by other means. Um and uh then you can also give things a nebulized adrenaline. You can also give, um, nebulized bronchodilators and things like that to, to cause it to dilate. Um, and always remember that your, you know, the patient must be quite a bit of pain. Um, then they must and they probably would have a fever as well. So it's important to give analgesia and antipyretics. Uh and then fluids, it's very important, especially if they're not feeding properly. Um, there, there, there quite likely to be dehydrated. So you want to give all of the IV fluids. Um And also, you know, another thing is if they're breastfed, make sure the, the mother continues to breast feed them uh just to make sure they're getting there. Um uh they're fluid uh for the day. So in terms of bronchiolitis, um I won't ask you guys, I'll just in this interest of time, I'll just carry on. So similar to group, just think, show them they're thinking holistically making sure not to agitate them and safety netting them again. Um And there's usually two major criterias for admission. One is um if they have poor feeding. So if they're feeding as decreased uh to uh to, you know, they're, they're um eating less than 50% of what they usually eat or uh they can't maintain the oxygen saturations when they're sleeping. So if it's, if it can't stay about above 90% when they're sleeping, that is there's a criteria for admission and one of the criteria for discharge is, you know, when they're feeding is resumed and I think it's events above 80%. Um And then if they can maintain oxygen saturations above 94% while they're sleeping, that is the criteria for, for considering discharge. Uh So you give oxygen if they're hypoxic, okay. And you can also give N G tube feeding um as well in severe bronchiolitis because um this is because if you, if you give other forms of feeding, it can cause gastric enlargement. Uh And then that in turn can kind of impair lung expansion and you know, impact ventilation. So this is something especially in severe bronchial, it is something you can consider, okay. Uh And they can also give suction if there's access, access. Um how, how um uh airway secretions, okay. And then finally, um epical otitis. Now I I've talked about this, okay. So similar to previous um previous diagnosis that I mentioned, uh make sure they're comfortable, okay. And this is very important. Um This is I can't stress enough the importance of any to be assessment in this patient because they have a very severe airway narrowing and obstruction, okay, which would need a senior kind of support, especially, you know, any studies might to come in and intubate, uh an ent might need to give in their input as well. And what something that would be worth mentioning was that show you should that show you so your breath of knowledge or hepatitis is you can mention that it's important not to do a, uh, ent examination or examination throat because it's already narrowed so much. You don't want to make it worse. Okay. Uh, and then, you know, giving supplemental oxygen and, um, anti antibiotics as well. So back caused by bacteria usually. Um, and then there's no surgical. Okay. So let's just a few key points. Okay. In a cough history, you know, asking about, um, whether it's worse at certain times of day establishing, um, it's nocturnal cough which might suggest it's asthma. Okay, conducting a relevant systems review. I've talked about this before using these very important to list in your investigations because you can get electrolyte abnormalities because of dehydration. Okay. Uh, and then I've told you that to one of the two important criteria for admission, um, which is for feeding less than 50% of usual and also not being able to maintain their 02 sats greater than 90% and also in epiglottitis, make sure not to, um, examine a patient throat. Okay. You might just cause them severe. We compromise, which can, you know, cause them to lose consciousness and things like that. Okay. Right. So let's move on to case too. Okay. Um, so, so this is a five month year old coming in with vomiting, okay. So I'll give you guys a few, few seconds. Can you, um, kind of put on the chat? What kind of things would you want to ask? How would you know what the uh SATS are during sleep. So basically that would usually, um usually, you know, when they comment, when you do an assessment in the pediatric assessment unit, you can kind of measure their oxygen saturations. Um And if, if um if they are, you know, sleeping, you can, you can measure it as well. But typically, you know, I think if, even if they're awake, if they can't maintain 90% that is a warriors of um but, but what especially one of the discharge criteria is that they should be able to maintain the oxygen saturation at least 9 94% and above during sleep and that may would make them safe for discharge. Okay. Yes. Uh So I'm just looking at the answers yet. Bilious. Yeah. Yeah. So I'm establishing at this bill is a non bilious. It's all feeding projectile blood frequency amount weight loss. Perfect. Uh Yeah. Brilliant, brilliant things to consider. Okay. So I'll just quickly go through it okay, similar to before establishing, you know, duration onset timing and things like that. Okay. But then you just want to show your examiner that you're thinking of potential diagnosis as well. So you can ask them, is it, is it worst after they've, they've eaten or after they've had their meal? Okay? Because sometimes, um you know, after, after food, especially if you have a lax esophageal sphincter or not, not like a week is a vigil. Um spink, you can get reflux. Yeah, in gastrace for your reflux disease. And if it becomes pathological, it becomes gastrace for your reflux disease. Um, you can, you know, you can get a lot of vomiting as a result. So you want to make sure to ask that. Okay and forceful vomiting. I think someone mentioned brilliant question to ask because that's, uh, that's not a common, common feature of pyloric stenosis. So you get the thickening of the pylorus, which is the outflow track from the stomach into the duodenum. And when it's thickened, um it can, can cause a lot of, lot of pressure build up because the narrow, the narrowing of the pylorus means that the contents of the stomach don't empty properly and then food collects and then it can just go back up and it's quite forceful as well because usually a lot of food collects and then it's expelled the other way. Um And then, you know, it's always good to expand on, you know, if, if they're bringing up what they're bringing up. So, is it, is it, what color is it? So is it green, which indicate, it might indicate it's bilious? Uh And then also asking whether it's, um, uh but it's, um, you know, not green or if it's orange. Um, that's usually non bilious and it's usually orange because of what they eat, but it's green and bilious formatting because of pile, okay. Um And also asking about blood as well. Um, sometimes, you know, repeated amounts of vomiting, especially for forceful vomiting can tear, the esophagus can get a bit of rupturing. Uh, were very concerning if it was read as well. And like, normally, um, if a child is unwell, you want to ask whether the activity levels haven't changed, have changed. Um, and whether they've been unwell recently and that's important if you're considering thing, something like gastroenteritis. Um, and that could be a cause of warm eating as well. So they might be systemically unwell as well. Um, and another important question that either it's worth asking is whether, how they usually sleep. Um, so when kids are usually sleeping on their front, especially if they have gas race of what your reflux disease, they can, they can force you to warm it because of the position. So it's usually advised to, you know, after feeding, keeping them upright for a bit, or at least if you're going to put them down, keep them on their back to prevent them bringing up contents and they can choke on it. Um, and it might, uh, it can cause cot death as well. So it is important to keep them on their back. Okay. And then systems review relevant. So, Gastro gastro um, systems reviewed talking about asking about abdo pain if they're, if they're old enough to talk, change in bowel habit, any diarrhea or warm it, I'm sorry, any diarrhea or constipation. Uh, and, um, you know, also also asking about steatorrhea because you're thinking of his stick fibrosis as well. Does it, does it float or does it have a distinct order? Um, and um, asking about dysphasia as well, let's see if it's gastro related and then cough shortness of breath again, as I mentioned earlier, linking back into rest as well. You can get recurrent infections if you're repeated warm eating field aspiration pneumonia and, uh, you know, a rash. Um Can you guys are, what, why would we be worth asking about a rash in someone presenting with, let's say warm eating and diarrhea. Can you guys uh tell me, tell me why. Yeah. Very good. Yeah, meningitis. Perfect because that typically causes uh war meeting as well. Cosmic protein, not really a rash per se. Um If it's, if it's I G A mutated. Um But what I am, yep. Perfect. Yeah, I think various different causes. But what I'm thinking of is actually celiac because you can get dermatitis about it for MS as a which is, which is a rash you can get because of Celia. It would be worth asking that as well. But yeah, very, very good answers as well. Um Okay. So in terms of the history, um so we're continuing the history, okay. Um Similar, it's similar to before I will just gloss over these. But it's another question worth asking if somebody coming in vomiting is whether they were born at term because one of the significant risk factors for gastroesophageal reflux disease is prematurity because since you, you know, you were born premature, you probably not had time enough time to develop your lower esophageal sphincter properly, which can cause you to reflux. Okay. And then the, the diet is, and feeding is very important here. Okay. Because what one of the biggest causes of reflux is when, you know, parents feed their kids um too often and also very large volumes of um food. Um you know, the breastfeeding formula milk or food at, at a time as well, which can cause them to reflux. Okay. Um And um and asking whether, whether it's changed as well. So if you're, if you're thinking, let's say, um um you should ask, you know, have they, let's say they having formula milk at the moment. Um And you can ask them or did they ever have breast milk before? Did they, did they change from breast milk to formula milk? Because you want to think something like that cow's milk protein allergy? Okay? Because that can, that can be because they were switched on to formula milk which contained um cosmic protein. Uh And if you're getting, getting omitting because of that, okay. Um And also how long you've been feeding as well? So the longer would, you know, kind of correlate with a larger amount of feeding as well. And also vet nappies is very important because a lot of warm eating, especially if it's recurrent warm eating can cause you to be dehydrated because you're losing a lot of water. Um So it's important to ask about the um urinary frequency as well and the hydration status, you can, you can find out and you can also look at things like the fontanel. So if it's depressed, that will be more in examination, that would suggest that, you know, they might be dehydrated, okay. Uh and then growth and development very important as well, especially if they've had chronic um episodes of vomiting. Okay. That means they're not getting the ad adequate nutrition like um uptake. Um and as a result, they may have some impact growth, okay. Um And which is why it's very important to, you know, assess their growth and ask us to see the red book and this might even be affecting their develop normal stones as well. Okay. And then finally, um just talking uh about the remaining parts of the history, which is uh family history, you know, asking about medical conditions and whether siblings are on well too. Uh and um one important thing you could possibly ask in some common vomiting um when it comes to family histories, whether they have had any specific specific medical conditions like autoimmune ones like, you know, type one diabetes Addison's disease. Because if there's a family history of autoimmune conditions, you know, you might may increase the likelihood of them having something like celiac being the cause for their vomiting as well. Okay. Um, and then, um, you know, similar drug history or never forget immunizations and drug allergies. Okay? And in social history always ask about social services and ice. Okay. So let's, let's take a look at this patient's presentation. Okay. So, came in vomiting. So having recurrent vomiting for the last three weeks, okay. Worse after feeding, she also cries during her feeds been less active and feeding less as well. Uh And she's been quite uh yeah. Uh you know, the frequency has also gone, gone down. She's only going twice a day. Um and she's been breast fed since birth but is sometimes given formula milk as well. Uh But her appetite has discrete which is no blood in the vomit or stools, no fever, diarrhea, dysphasia or short of breath. She was hospitalized two weeks ago due to pneumonia. Uh, no signal family history and sorry medication, no known drug allergies. Uh She is uh living at home with her parents and m eyes their first child. So she was born at 34 weeks. Gestation were emergency section due to premature rupture of membranes and stay in the UK sorry, Nick you neonatal intensive care unit. Um And as a result, um she's sorry because she was born premature. She's up to date with all the immunizations and has been meeting her development of my stones, but she has not been growing well, okay. And the mother is worried about this So what, what kind of, what would be, um, your top differential? Can you guys put it on the chat for me? Yeah. Okay. I'm seeing, uh, to private messages. Any, anyone want to hazard a guess that's what's going on. Perfect. Yep. God. Yeah. So they have a lot of risk factors for God's of prematurity, firstborn. Um, you know, um, it's worse after feeding. Um, and, um, yeah, things like that. Okay. And what will be some other differential diagnosis? Mhm. Pyloric stenosis um could be, could be less likely because pyloric stenosis will be more acute. Um and then gastroenteritis. Yep, gastroenteritis. Very good. Yeah, especially um even the timeframe cows milk allergy. Perfect. Yeah. So I mentioned the history that they given formula milk sometimes celiac cf or perfect. Perfect answers. Yeah. So um stop differential is gastrace for geo here and other differentials are Celia gastroenteritis. Cosmo could be um cystic fibrosis. Well, okay. Right. So a few spot diagnosis before we go on to talk about investigations, I'll give you a few seconds. What do you think? Um this infant is presenting with? Mhm. Perfect. Perfect. So, you know, they have significant in uh autoimmune disease in the family um and symptoms of celiac disease. Next one. Yeah. Perfect. Perfect. Cosmic protein allergy. Yep, because they were recently started on formula milk and that is most likely to have caused the symptoms to manifest. Okay. The next one. Yep. Perfect. Yep. It is gastroenteritis. So the bloody diarrhea, um, and then the classmates being unwell as well. It could be something they eat, uncooked, uncooked meat and then finally lost us. Difference for diagnosis. Construction. Mhm. Yeah. Yeah. Ok. Ok. Obstruction. Yep. Constipation. Yeah. I was, I was going for, um, constipation here. Um, given, given the age, um, volvulus and things like that would present very, very early on usually in the onate age. But this is more like most likely to be um, constipation. Um, which is why I put it a bit of an older, older infant. Okay. And she hasn't opened her bowels, um, in about a week's time. Um, and uh, yeah, okay. And this is something called retentive posturing. So this is, um, so usually kids with constipation find it very painful to pass stool because of that. They strain and they adopt this posture, you know, where they got their legs straight, they're flexing their back and neck and that's, that's to hold in their, their stool and not pass a motion because it's so painful for them and says that the position they adapt to not to overcome the pain. Uh, and sorry, not over cos sorry to, to not have a uh to not pass the uh motion and it's one something that can be seen as well. Okay. So when it comes to pediatric vomiting, acute, chronic, okay, I won't spend too much time on it. Um, but it's important to consider, which is bilious, non bilious, depending on their positive position, whether they're proximal or DeSisto uh in, in the junction of the duodenum where the bile ducts at the ample of water. Okay. If it's proximal from that junction, it's non bilious. So it's closer to the stomach if it's DeSisto, so away from the stomach towards small, interesting, it's more likely to be bilious. Okay. And I've highlighted the differences. Okay. And I've briefly, um and for those who attended our finals, easy session, I I've gone through this in more detail, so I won't spend too much time in the interest of time. Okay. But these are some good differentials to remember especially um in a neonate things like interception. Um, sorry, housebound disease, necrotizing integral height is because the emergencies that usually need surgery. Um, and also, you know, there's a risk of bowel cooperation so these need to be recognized promptly. Okay. Um, um, yeah. Okay. So in terms of investigations, okay, similar similar to, to rest, you know, you do a two E basic ob G eye examination. Very important here. Do not forget that. And you do very important blood's okay. Use the knees, you'd want to do again to look for any signs of dehydration causing any electrolyte abnormalities. Uh You'd also want to do FBC to look for infection or any signs of anemia because you can get iron and iron deficiency anemia. You can also um get, get other forms of anemia as well, um lefties, two liver function, capillary, blood gas again to look for any abnormalities in the metabolic or uh status of the patient. So, usually metabolic acidosis can be caused because of dehydration. Okay, because you have a low circulating volume as a result, there's um there's an accumulation of hydrogen alliance. So there's less excreted because you've got a less, less amount of circulating volume of fluid or, you know, blood. Um and then you do things like blood cultures and then you can do special uh specialist um investigations for celiac looking at total IgE anti TTG. You can also do endoscopic biopsy testing. But that's if you, if you get the positive for the antibodies, okay. Uh And then you can also do iron studies be to afford it because you can usually get either iron deficiency anemia, which is a microcytic anemia or you can get a macrocytic anemia because of you to afford it. But sometimes patient's can be fixed with a mixed anemia. So it looks like a normocytic anemia because they have a mix of macrocytic and microcytic anemia. And I think important mentioning abdominal X ray. Uh you know, look for any acute pathology, you know, dilation and things like that because of constipation and, and various other things. Um And then Iraq chest X ray, if you suspect about corporation, this is very important in, you know, things like necrotizing enterocolitis. Um um which you know, we want to check for your peritoneum, which is, you know, air under the diaphragm and an abdominal ultrasound, which is typically used in, if you suspect interceptions, you can see a ring because you get telescoping of the bowel. Okay. So that's an important one to do. Um And you can also in, in pyloric stenosis, you can visualize the chicken pylorus, um and then, which confirms the diagnosis and then you can also do other special tests like rectal biopsy to confirm Hirschprung disease. So you look for the absence of the uh nerve plaques I, which is, you know, which is a typical feature in Hirschprung. Uh This now plexa is responsible for the paris analysis of if the uh last part of the colon and the rectum and then skin prick testing. Um if you suspect I G mediated cause more protein, okay. So in the interest of time, I'll just quickly gloss over this. Okay. So in terms of God, um I think it's important to educate patients' families and warn them of possible complications because of it. So they're more likely to get aspiration pneumonia. And also the first step in managing is giving them advice on feeding. So feed a smaller volumes okay and more frequently so that they're getting the adequate nutrition and this prevents, you know, the stomach from over filling, keeping their head at a 30 degree angle and also keeping them um on their back and making sure they're not on their front uh so just to reiterate, keeping them on their back to prevent card debt, okay. Uh And then you can give things like PPI S if it's severe otherwise you can trial, um Algeria therapy, which is basically some Gaviscon or thicken formula corn starch and things like that just to, just to prevent that reflux, make it a bit more dense and so that it's less likely to go back um, the wrong way and then listen, found application. Um just, just uh making a titer band around the video spincter and this is very rarely done in kids. It's only a very severe disease and it's more more likely to be done in adults. Um And then you have celiac disease, okay. Um I think the mainstay treatment for celiac I think were mentioning is removing gluten from your diet. Um So it would be nice if you can demonstrate what kind of foods contain gluten, um like wheat barley and Right. Okay. And you can also give steroids um uh if they're, if they're not responding, especially you can give things like steroid cream like dapsone. Um If they have dermatitis, herpetiformis. Okay. Um ok, before me, uh sorry, just one more, one more slide. Okay. And then cosmic protein intolerance allergy, which is one of the most common ones that you notice around um in the first six months or so. Um Usually, especially if they, if the child is switched on to cosmic protein, they have an allergic reaction to it, um or they're intolerant of it. Okay. And the mainstay treatment is stopping them from consuming any products containing cosmic protein. Okay. And then if they are also being breast fed, their, their mothers are encouraged to breastfeed, continue breastfeeding. And uh you know, if they are not being breast fed, they will be started on extensively hydrolyzed formula milk, which is broken down proteins uh so that it's easy to digest and also less likely to uh cause a reaction. Okay. If that doesn't work, you can, you can have even further broken down a minor acid based formula book. Um and then slowly this is more specialist level um um treatment is that, you know, you can use the milk ladder to reintroduce cosmic protein slowly into the diet. So usually starting off with very processed cause milk. So things like, you know, biscuits, um cookies and things like uh where there's gonna huge preparatory process. Um and then slowly moving up the ladder to less processed milk products like yogurt and then finally moving on to uh I will surely train the body for it. Okay. And then if there are severe symptoms like failure to thrive, they're not growing properly, you refer to a specialist pediatrician. Okay. Right. Okay. So uh some key points to remember, uh you know, explore a bit more about the vomiting, you know, whether it's worse during certain points um after certain activities like feeding conduct a relevant systems review, ask about, you know, abdo pain, potential bowel habit and things like that. Breakfast for use any similar, if you suspect dehydration. Um, and then the mainstay treatment for Celiac gives room of gluten and then small and frequent feeds, um, is the first line of advice that you should give the patient's, um, two parents of patient's with God. Okay, to prevent that reflux. And then, um, okay, we'll move on to the final case. Okay. So I know um I think bear with me for another 10 to 15 minutes. Okay. And then um we will be done. Okay. So in the interest of time I'll just quickly run through this case. So this is a seven month infant presenting with the fever, okay. Um So in terms of the history, okay, um this is what they're presenting with. Okay. So the fever has been there for the last three days, ok? And it's 39 degrees Celsius at maximum uh analgesia, sorry, antibiotics, such couple was given but didn't help. And then a rash also appeared. It's very good important to ask what rashes if someone coming in fever. Uh And it's also you can ask about, you know, where, where did it start first? You can delineate different conditions like, you know, in missiles, the rash usually starts in the face, you know, behind the ear. Uh And then you can ask, uh you know, you can ask them to describe it if possible, but it's important to establish, um, or whether the rash came before and after the, after the fever as well because I believe, um, in, uh, in certain conditions that can be before, uh, and then, you know, asking about the feeding, uh, and the activity levels and the, you know, very, uh, habits. Um, and, um, you know, with the, you know, other stuff. Okay. And the systems review, like I mentioned, anyone coming to the fever, it's always good to ask about seizures, okay. Um And ask him about, you know, changes to bowel habit. Um And, and wait, especially if you can um if they are coming in with similar failure, two tribes. So they're not growing well. Uh and he's had episodes of warm eating, okay. Uh And then rest of the history, okay. Nothing significant in the medic past medical history. Uh Nothing significant in the birth history. Uh So in terms of feeding, he's currently being weaned off breast. Well, because he's at that age is um seven months and he started on mashed up foods. Uh but he's been refusing so his food intake has decreased. Um but he has been growing well. Um and it has not been affected um as as of yet if it is going to be, uh and he's met all his development milestones, okay. In terms of family history, nothing relevant drug history. Something important is the mother is unsure of whether he's up to date immunizations. You know, this should be kind of um ringing alarm bells for you because you know, a lot of, lot of medical, a lot of the infection, infectious diseases, senior pediatrics can be due to poor immunization. Uh no, no drug allergies and always, you know, making sure social services are asked about and then ice as well. Okay. So, so this is uh given that information and this is the rash that the patient's presenting with. What would your top differential diagnosis be? Okay? I don't know else. Would you be able to launch the poll? If not? Um It's no, it's okay. We'll give it, give it 30 30 seconds to a minute and then, okay, we're getting a mix of answers. Mhm Give it a 20 seconds or so. Um I don't think the polls are working at this point. So guys feel free to put it on the chat. Mhm So um most of you have said the mix of answers. Okay. Um So before I go on to reveal the answer, what, what, how would you describe this rash? No. Yeah. How would you describe this rash? Can anyone put on the chat? How would you describe this rash? Uh Macular popular, generalized, widespread. Yeah. Diffuse. Yeah. Um Not really macular popular. Can you be a bit more specific? Um And it's uh appearance uh not really noticed. Not really. Uh Yeah, I think someone did say uh Yep, Petesch. E oh Yeah, perfect. Um I would say it's particularly it is debatable, but I would say this is more petesch eo um and um all Petesch your rashes are nonblanching. So, Petitioner rashes are just because of bursting of small blood vessels uh at the surface of the skin which cause it. Uh and it's and all petesch your rashes are nonblanching and the one of the most common ones are due to, in fact, meningococcus septicemia. Okay. The reason why this is the top diagnosis is um um this is what diagnosis not to be missed. So it might not, you know, necessarily be managers always have to see me, but it's important to keep that in mind because, you know, things like it's initiating sepsis six protocol is very important. Um And if you, if it's not promptly treated those severe morbidity following it and also mortality as well. So, and when a child with fever comes in there with a rash, your, your one of your top differential diagnosis should be mental cocoa septicemia. Okay. And this is a petition, a rash. So you can let pit pinpoint pinpoint rash, macular popular one will be with more diffuse and bit larger. Uh sorry, we will be a bit larger. Uh But this is more of a petition rash, okay. It's not really, it's less like to be covered sake and scholar because you didn't get the things that conjunctivitis, strawberry tongue and things like that. And um yeah, missiles and a Rosalynn phantom, you get other things like lymphadenopathy and things like that. So it's more likely to be manager cocoa septicemia. Um, but this should definitely be your top diagnosis. Okay. So, before we go on to, um, uh, you know, talking about investigations and things like that, let's, let's go through some very quick spot diagnosis. Okay. What do you guys? Um, I think the first one is. Yeah. Perfect. Yeah. Um Yeah, you get the classic, you know, this uh conductive itis rash fever and usually a fever, very high fever, greater than five days. You get like uh retinopathy, next, next spot diagnosis. Mhm Brilliant. Yep. It is very important um because um you have to remember that, you know, um not too great with so I might have missed the mmr which is why you get measles and uh this rash started behind the ears like I mentioned, that's a, that's a typical feature of measles as well. Um So yeah, so that rash has started behind the ears and unsure of vaccinations. Okay? And then the last one. Um Perfect. Yeah. So uh in the interest of time, I'll just quickly lost over it. So, yeah, it's quite a sand paper texture, um like rash and you get fever, sore throat with it as well. Um How can you tell between rubella and me? So, so measles that I mentioned um you would, you know, get the, get the rash typically starting in the, you wouldn't get that in rubella and there's various other other features, but there will be one distinct feature um in the interest of time. I think I'll quickly go over these. So, can you guys tell me what this, this would be? Just as a quick picture spot diagnosis? Yeah, perfect. It is. It is a red, pink macular sandpaper rash. Seen it. Scarlet fever. What, what, what my, what is the next one? Mhm. Can you tell me what the, what the same, um, sign is? Yeah, I think I saw, yeah. Strawberry Tron. Yep. Also seen in, uh, Scholar, Scholar Fever as well. Uh, and also Kawasaki and then finally, what would this be? Mhm. Perfect. Perfect. Koplik spots measles. Yeah, you guys are really, really doing well, which is really nice to see. So, given, given the most likely diagnosis, what investigation should be carried out immediately. What would be the most important? Oh, there we go. We got a poll. So I'll let you guys answer on there. I'll give you about 30 seconds in the interest of time. Sorry, if I'm brushing a bit. Um, I don't want to keep you guys here for too long. We're almost done. I think another 10 minutes or so. Mhm. I'll give you guys 10 more seconds. Yeah, I think most of you have gotten it. So I just ended here. Uh, so most of you went for b which is, which is correct? Okay. It is blood cultures because you want to initiate sepsis six as soon as possible. But something to remember. Um and this would show your breath of knowledge in, in, in uh Rosky is mentioned that, you know, you don't have to wait for the results of blood cultures to start antibiotics. You start antibiotics immediately. Uh And then you would, once you got the results, you can change it to more specific antibiotics according to microbiology advice. Okay. So it's important to start antibiotics even if you don't have the blood culture results um of the specific organism causing it. Okay. And lumbar puncture is contra indicated uh in manage kokko septicemia. Okay. And you do these investigations later on if need be CT head, if you suspect increased ICP using needs for dehydration FBC um to look for signs of infection. Okay. In terms of investigations, I'll just very quickly run away to is very important here because you know, acutely on word patient, um they need urgent senior um senior support and also thorough assessment. Okay. Um Doing a neuro exam, uh any anti examine, you would probably need to do a dermatology exam as well just to confirm the rash, doing a throat swab if you think um if it's, if you wanna isolator, if they are also coming to the sore throat, um and then you want to look for a group, a strep which means it gets colder fever. Uh And you do the same, same types of bloods, as I mentioned, I won't spend too much time on this. Um And then you can do some specialist test like I G M antibodies which usually detected after, after onset of ration measles. Um, but it's not routinely done. Okay. So final question, uh, what, what antibiotic, um, must there be started on? Um, this is what, um, this is um, very important. Um And it's an important consideration especially um and I mean, in a hospital setting, what would we'll be the uh I think most of you have got it. So I will interest of time. I'll move on. Think 2% of you answered. Which is brilliant. Yeah, it is kept track zone. Okay. So they're less greater than three months of age you'd start with kept track soon. Is there less than three months? You would want to give a combination of amoxicillin and kept track soon? Can you guys tell me what uh where, where um is there any any any instances where you would give ciprofloxacin? Is there anyone you would give soup flocks in, in, in, in this kind of situation? Mm No, no, no, no because yeah. Prophylaxis. Yes, perfect. Yeah. So you give your the clothes context prophylactic super fluxing, okay. Uh And then yeah, so manager cockle septicemia very, very quickly, okay. You have to isolate the patient hospital. Um There'll be something uh something good to say, show your breath of knowledge. Okay. And it's a notifiable disease. Um And you have to give uh Super Fox and prophylaxis to close contacts. Uh it to be important sepsis, six very important uh you know, giving supportive treatment, oxygen and fluids and do not give steroids, steroids because it's been shown to have negative outcomes in patient's steroids aren't given in manager Kokko septicemia, but it is given in meningitis. So remember that distinction as well. Uh and it's also good to measure urine output. Um and uh neurology as well because things like raised ICP can also happen in, in many magical septicemia. You want to give things like paracetamol to bring the fever down, okay. And then Kawasaki disease, okay. I've, I've talked about it. Um you know, it's important to warn patient's of possible complications as well like coronary artery aneurysms, which is why it's important to do an echo scan to look for these. Okay, because you can get severe significant morbidity because of it. And um it's important to also give other treatments like um intravenous immunoglobulins and you can also give aspirin. So this is the only pediatric condition where they give aspirin because aspirin can trigger something called race syndrome. I won't really go into much but it can cause um severe neurological dysfunction. Uh And one of the triggers is aspirin. Aspirin can trigger Reyes syndrome, which is why it's not frequently given. But uh the outcomes following Kawasaki is very, very poor, which is why they, you know, they consider giving aspirin and then you give supportive treatment um, as well and then scarlet fever. Okay. It's important to, again warn patient's family members of the complications. You can get that this media rheumatic fever, etcetera. And it's also a notifiable disease. Okay. Just something worth mentioning as well. Should the examiner your breath of knowledge and that they can return to school, but only 20 four hours after starting antibiotics and the antibiotics they usually started on is penicillin and that's for 10 days, okay. And you can give us to my significant allergic and always supportive treatment important. Okay. So almost done some key key points to remember when a patient presents with fever, always ask about a rash or seizures they have okay. Uh and always remember immunization history, okay, like they have an mmr vaccine, whether they've had the meningitis vaccine. So as you remembered in the, in the, in the history, uh the mother wasn't sure whether the child has had all their vaccinations, so they might have missed uh some of them meningitis. Uh may just be a more see vaccines and as a result, they've developed it and also have a low threshold for initiating sepsis six and you know, with infection because you, you might not wanna, you know, live with the consequences of it. Um And then you have to notify public health um if it is scarlet fever or court septicemia, okay. Right. So last couple in the next two minutes. I'll just very quickly go over pediatric basic life support and shocking. Okay. So if a patient is unresponsive, okay, you'd wanna firstly call for help or call this number to, to, to uh and then you'd want to open the airway. So you'd want to do a head tilt, chin lift. Okay? And if that's an unsuccessful, you can do a draw trust, but it's always important. Remember, you wouldn't want to do a draw trust in someone with a survive if you suspect a cervical injury, okay. But sometimes if the priority of the airway, so it's greater than uh for the worsening a cervical injury. So you might consider that as well, but typically they do have a cervical injury and they don't have severe airway compromise. You consider not doing a jaw thrust, okay. And then you can assess for, you know, signs of life they're breathing normally. So you can keep your, your cheek on, on close to their mouth and see if there's uh you can feel their breath, you can listen, listen for sounds of breathing and also look for any chest, chest or movements and if they are breathing, that is a good sign, okay, then you'd want to immediately assess them using it to the approach, give any, any supportive treatment, um getting access to, you know, give them fluids um and also monitoring uh various different parameters like oxygen and calling for help. If needed. But however, if they don't have signs of life, so if they're not breathing properly, you can't feel the breath against your cheek. You'd want to start five rescue breaths immediately. Okay. Um, and if there is, if you're someone well trained, you can give something called bag mask ventilation, which is much preferred. Um, and you can, it's much easier to give as well, but you need to be trained. If not, you can give rescue breaths. Uh And then if it's unsafe to ventilate, you can straightaway, move to chest compressions okay. And then if you given fire rescue breaths, there's still no signs of life. You want to give chest compressions okay. Uh And the ratio is different, two different two adults, it's 15 chest compressions to two rescue breaths, okay. Uh And then you want to attach a defib if you can get someone else to attach a defib an E C G monitor while you do that to monitor their heart. And then if that is unsuccessful, you move on to the advanced support life life support algorithm. But this would be something you know, um which I mean, it depends on your, your, your university, but it is something that could, that could come up if you have been taught it okay. And then finally the choking algorithm. Uh So this is if you suspect uh foreign everybody aware obstructions to someone very acutely, you know, they were playing with their toys and then suddenly they become, uh, they start choking. Um, and when they come out of breath and then what you want to do is talk for help, get more people. Um, and then check whether their cough is effective. Okay. So, an effective cough would mean that they're able to speak, um, speak. Um, at least a few words like and communicate, uh, their breathing would be compromised. Uh, and they will be quite more alert, but an ineffective cough would mean that, you know, they might be losing consciousness, they might be going sign, not getting cyanotic. Uh, they won't be able to speak in sentences or even words. Um So if, if the cough is effective, so if they're able to talk and you know, some what breed, if they can take a deep breath in before they talk, um, and if that's a yes, then you have to encourage them to cough with. It shows that it's not that severe obstruction. Okay. And encouraging them to cough is the best, best approach because it's, it's the safest possible and the most effective, um, because you don't have to do any additional maneuvers that might cause injury, you know, injury to their ribs and things like that. So encourage them to cough and then check whether there's an improvement, okay. But however, if they have enough ineffective coffee and they're losing consciousness, they're getting cyanotic. You have to call the recess team immediately, okay. And you have to check whether they're conscious, okay? If they are unconscious, okay, you wanted to start basic life support immediately. So you want to check the open there where we head to chin lift, jaw thrust, depending on the situation. And then try and rescue beds and they're starting chest compressions, okay. But if they are conscious, um you'd want to alternate with back blows. Um and trust uh so you'd want to, you know, back blows, you'd want to keep them, um keep them on their front and then using the palm of your hand just giving five consecutive back blows and then checking for improvement. If not, then you would give chest chest thrust uh in an infant. Um And you would give abdominal thrust um in a child. So you don't want to give abdominal thrust in an infant due to, you know, risk of damage to their, to their ribs because they were quite tiny. Um And that the aim of these back blows and thrust is to increase the intrathoracic pressure so that you can forcefully expel the object, okay. And if it is relieved, then you'd um they'll need urgent follow up. But if it's, if it's not, you have to, you know, repeat that, repeat this process over and over again. Brilliant and yes, that is it. Thank you guys for listening and sorry, we ran slightly slightly overran a bit. Uh I hope you found that useful. Um uh I'm sorry, I couldn't answer any question towards the end? Um Just because I was trying to, you know, make sure to um finish as soon as I could. But if you do, if you still do have um any any questions let me know. Um hmm. Ok. Pre too someone is asking me, is it possible for patient with magical concept? See, we have to present without raced ICP. Um So um they can present without race ICP. It doesn't have.