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Hi everyone I'm just waiting for a few more people to join and then we'll get going all right. I think we'll start um If you have any questions just put them in the chat and try and answer them along the way, um so we're going to be just looking at pediatric history taking and the newborn baby examination uh also known as the night p examination, which is the newborn infant. Physical examination, so we'll start off by just looking at the pediatric history taking very similar to adults. Just a few more things to concentrate and focus on um as and I'll go along that as we go along, So, initially opening the consultation so very similar to adults, introduce yourself, wash your hands and put on appropriate PPE and confirm the child's name and date of birth is quite important because you want to be able to know. If you know the child's age, you can, kind of you can change your questions more appropriate for that age, essentially clarify the identity of those with, with the child and the parents, siblings, grandparents Social workers um sometimes it might be better to speak to the child on their own uh that can be quite difficult to do so um just because some parents might understand but usually the way i go about it is just say usually I like to speak to the child on their own, um do you mind stepping out for a few moments and then I'll call you back in um and that usually goes down okay uh and this is a good time to also just while you're introducing yourself and everyone's introducing themselves just to observe the child's behavior and the initial appearance. Do they look very unwell are they on the bed um quite flat, quite pale. They're working very hard to breathe or what are they running around, behaving appropriately or are they quite shy. Um Obviously, in any initials of seeing other bleeding, do they have a deformed uh limb or do they have any bruising or anything like that that's from the initial things that you'll see, also a good time to build some rapport with children, So communication as you probably know is very very important in pediatrics, so when you're trying to get a history, um children can be quite shy um so building a rapport with them is quite important, ideally try to get down to their level to the eye level to speak to them directly um and try and direct the questions obviously depending on the age of the child, try and direct the questions to them rather than just speaking to their parents especially for an older child as well. So if someone says 60 and 15 the teenagers, you wanted to speak directly to them, direct questions towards them rather than directing to the parents um and pick out a new thing, pick up things kind of that will help. People report if they've got sports t shirts on, if they got man united or chelsea, searcher on just kind of just talk to them about their favorite sort of sports or favorite players, etcetera, and that just kind of help them calm down a little bit and ease into the consultation. So presenting complaint um this is very same as the adults. Essentially so you want to start off with very open questions, so things like so what's brought you in to hospital or gp today, what can I help you with today um that just keep it as open as possible and let the child or the parent do the talking initially um then moving onto history presenting complaint so again very similar you want to start off with general questions and then make the questioning more focused, so things keep it general initially, so how long has this been going on for have you had anything similar in the past, anything that makes it better or worse. Have you tried any medications which help um and then you want to get a bit more focused, so for example if they've come in with a cough, you want to start asking more um specific questions around the cough how long has it been going on for again, that's quite open, but then going on to, is it productive are you bringing up anything with it, have you ever brought up any blood, etcetera, etcetera. The good way of assessing sort of taking history from uh people who present with your children represent with pain. Is a Socrates method, so Socrates method is something that we learned in medical school and I think a lot of people music uh just around the country and it's just a good way of getting a comprehensive history on pain, so socrates essentially it's an acronym, so site, so for children to say can you point to where it hurts um and then on set when did the pain starts to come on suddenly or is it getting progressively worse were you doing anything at the time when the first pain first and started so where they're playing sports with genetic etcetera, etcetera. Character is it a sharp, stabbing pain or sort of adult achy pain or just you can ask them what does the pain feel like that can be quite difficult for children as well, So giving them a bit more of a um make more options can be better rather than just keeping it open in that instants, so things like is it a sharp pain is it quite does it feel like someone's punching you in the tummy or does it feel more of a dull achy pain, is it there, constantly or does it kind of come and go, does it go be, says you're trying to figure out if it's constantly intermitted pain, then um are, is for radiation, does the pain move anywhere, so does it go from. For example, does it go from the umbilicus. The right iliac fossa give you a bit more idea of pain um so the pathophysiology behind the pain and then associated symptoms, so anything else any other symptoms that you get alongside the pain, so nausea and vomiting, we change in bowel habits, movement restriction, etcetera. Time has the pain changed over time, so this would be sort of as a pain become worse is it getting better or do you feel like it became worse and then now it's getting a little bit better um and then exacerbating or alleviating factors so is there anything that makes the pain better or is there anything that makes it worse and then severity again. Um best way to access is just say on a scale of 1 to 10 10 being the worst pain you've ever experienced why would you rate it now. This is very similar to adults. Um It's just trying to have a bit more focus and it's rather than keeping it open, it's a bit more appropriate for children. Um So feeding history and urine output now that's very that's one of the things that's very different from adults too children. This is a lot more focused in children. There's a lot more important to ask especially with younger children um a lot of kids that you see who are unwell. The feeding is the first thing to go um and then slowly can urine applicant can reduce as well and you want to look out for things like dehydration. When you're assessing these, so, children, when they are more like I said they first thing that goes is they're feeding, so you want to ask them are they the other for ask the parents are they feeding as usual. Um If not how much are they feeding, parents will just say normally I feed them four ounces or two aunts, or whatever every few hours over four hours, but now they're having less than that um Usually, it's fine for children, so feel like I said feeding can reduce an illness, just like you can redo, reducing any anyone adults or children. Um The parents become very concerned when children are to feed a little bit less. It's not usually a problem unless there are other signs of dehydration or if they're sort of having less than 50% of than usual feeds um alongside other symptoms of sort of dehydration and things that, and then you are a bit more concerned if they're still having um more than about 50% of their feeds than it's less worrying you want to know are they breast fed are they formula fed or there we'd onto solid meals um and age can help you with that as well, um so with their formula fed or what kind of former are they on at the moment uh and how often do you feed them, etcetera. And then there are they actively wanting to feed or are they pushing away so actively wanting to feed so that they're actually interested in food um and actually sort of that's a bit more of you'd be less concerned than kids who just don't want to feed at all. As you know kids, all they do is just feed them feel and sleep so uh If they're not wanting to eat, then you kind of a bit more concerned, so a ballpark amount for young babies until about six months, about 10 months. Uh There's no strict kind of criteria of how much they should be feeding from what I've seen and from what I practiced um around 100 and 50 mils per kilogram for 24 hours that's okay if they're having that much amount of feeds and you're not too worried, So parents usually will feed a bit more than that um so when their kids, they become unwell and they're feeding decreases. They're they're really concerned, but if they're having around that much 150 most peculiar amputee. Um it's not not not concerning, um not well, not as concerning, that can be more in other children as well, can go up to 200 miles per kilogram per day. It's very dependent on child, but usually the ball pacman is about 1 50 miles every day um and are they still passing urine slash having wet nappies, so usually just uh with every child I just go for are they still feeding and the feeding as usual and they say yes or no or are they having wet nappies as usual um wet nappies a bit more important than dirty nappies. So you want to know more about the urine app, rather than this still still habits. Um Feeding sort of fluid and hydration status is a bit more important than they're if they're off their sort of food um and then so where nappies how many wet nappies have they had today. Uh The nappies quite heavy or dry or do they even have um urine crystals. They do you know they're a bit more dehydrated, obviously keeping in mind other signs of dehydration things like tachycardia, um sort of dry mucous membranes um and if it's all lethargic as well, so all of those kind of things put together will give you a good picture of, of the child um sort of the hydration status and the feeding history while they're unwell and then you want to go into assistance review uh so just a quick fire questions um just to see how they're overhauled it during overall, so any vomiting, any changes to the stool habit, any diarrhea, constipation, any fevers now fever that is an interesting one because a lot of the time parents will say yes they've had a fever um and you have to ask them have you taken a temperature a lot of times, they'll be like no they've just been warm to touch um. And then even if they have taken the temperature, it's important to ask them how they're taking the temperature. Sometimes they take the four heads of the infrared forehead ones, which might not be as accurate as say the ear ones or the, for younger children, so the under arm ones, the axillary temperature pro, um and they have to be usually over 38 is what's classed as an actual fever. Um any fevers and at the age of three months is a red flag and the nice guidelines um flags that as sepsis, so they need to be sent to hospital or admitted and treated their sepsis essentially um As for any rashes As well, a lot of children get sort of viral rashes um but I have seen a couple of times as well, so, a child may just have a rash and that's the only symptom um that they've come in with, but when he checked the observations there floridly very unwell, they've got um fevers, their heart rates through the roof and they can be thoroughly septic as well just with just the rash alongside a rash. You wanna ask things like like you said you've already asked about vomiting, but any sort of, are they what their behaviors like are they more lethargic, are there. More drowsy is a rash blanching um kind of think of meningitis. Um any coughs, any increased work of breathing. So kids at the moment, especially lots of lots of viruses going around don't have coughs. Um So you want to just ask increased work of breathing is quite important, so are they can you see them sucking in so their tummy, a, they're sucking in, can you see their ribs from the side, can you see them sucking in from sort of the windpipe area um So that's called a brachial tug or if they have any intercourse. What's apostle recessions um Those are things to ask parents as well and he cries or symptoms. Any things like what he knows sneezing and change in their weight, so if they have their um from the, from their childhood, they'll have their red book, which is what we use to measure sort of their general growth, health visit things, and that they come and measure some of their weight and their growth um So have they have decided to lose weight or are they difficulties of gaining weight. All of those things uh parents no quite well um and like I said behaviors are the drowsy or this sort of alert and playing as normal and also is anyone unwell in the household, have they been in contact with anyone well um and the classic story usually would be yeah, I've got a toddler who goes to nursery and he's got he's got a bit of a cold and that's usually the source of infection, other children, um and then past medical surgical history very similar to adults. Um The only addition is that we focus a lot more in the pregnancy and the neonatal history. The questions to ask is whether any complications prenatally, so, any problems with the scans, any complications during the pregnancy, any how are they what was the murder delivery where they're born by a C section or vaginal delivery. What gestation were they born at what was their birth weight and where they admitted to hospital straight after being born, so whether admitted to the neonatal ICU or the special care baby unit now the reason that you'd be asking these questions is um So say, if you have two children, so you have a child that was born on term good birth weight, uh No complications during the pregnancy born either c section or sort of vaginal delivery, uh, and they weren't admitted, so they were just they were discharged him within 24 hours um And you have that child that comes in with a bit of a cough and you're thinking things you're thinking maybe bronculitis, they got a bit of a cough, not particularly working hard to breathe um And now you're on the other hand, you have a child that was born premature, so depending on how premature 28 weeks of station 23 weeks um There are two weeks um and they spent some they were admitted to the neonatal ward straight after being born and they were quite small as a child um any sort of complications during pregnancy, etcetera um And they also come in with the cough, similar similar sort of presentation as the child. Um They also have bronculitis. They might need occur. They might need sort of further assistance with their breathing, and so you have a lower threshold to admit those children as opposed to the child that's a bit more that's was born in time. Um I didn't have any complications, so you want to ask those questions just to be a bit aware of kind of way of threshold sits on admitting into hospital or can that child become quite underworld quite quickly, and you want to just ask a developmental history as well, So age is quite important, so are they meeting their milestones, have, there been any concerns from the health visitor or from the school at all about how they're getting on and how they're developing. The rest is. A similar past medical history are they do. They have any other medical conditions, um do they take any medications including what dose and what route they're taking the medications, etcetera. Past surgical history and immunizations important are up to date with the immunization schedule as well. Uh At this point, there might be a good idea to say if they say no to sign post them as well, just asking just say it's a good idea to get your child up to date with the immunization. Um You want to ask drug and family history as well, so like I said any regular medications, so which medications, what does what route um any allergies um two medications, or anything else as far as they're aware um and any significant medical conditions that run in the family on either side. So things like you want to look out for any young deaths um Any problems, any sort of congenital problems that runs you know either side of the family. Um Social history is quite important for children as well, so who lives with them at home, are they known to social services, are they under a child protection plan, other childhood need um and then is everything going well at school. There's an acronym here called Heads and essentially you can do a quick version of this When you're asking, I mean not it's not always appropriate and you may not always have the time to do a good goods or in depth social history um especially in things like a any, um but if you wanted to ask more of more of a thorough history of social size, so you want to say what's the home and relationships site, so who who lives at home do you get on with them. Do you have siblings, um do you go to school, so education, employment, so do they go to school. Do you enjoy school what your favorite subjects. These kind of things help people report as well, um do they have a job if they're like 16 years old, eating, so you want to ask them you wanna might focus that on more um if you're worried about things like eating disorders or other mental health disorders, activities and hobbies what do you do in your spare time, what kind of sports do you like to do and so about drugs, alcohol, tobacco, um texting relationship, especially about things so these kind of things drugs um text in relationships self harm, depression. You want to ask those questions and kind of thinking of safeguarding around that as well as well as obviously um wanting to care to do sort of any medical interventions and things like safety and abuse as well. So again focusing a lot on safeguarding on that side as well. So social history is important especially for if you're worried about there's any sort of um anything in the history that doesn't sound sound correct or sound right, so you want to make sure there's nothing else going on, nothing sinister essentially and then um I like to end it with a bit of ice essentially. So isis just ideas, concerns, expectations uh very common in um sort of gp practice uh in community, So ideas so do you have any idea of yourself what this could these symptoms could be a lot of times, they'll say no, but sometimes you'd be surprised when people would be like yeah, I think it's this um and I think this is this because my other child has this, etcetera, or concerns, is anything. Specifically that you're concerned about, so say, if someone's got uh significant family history of some cancers, they can be quite worried about that, so they can do like. I'm really worried that this is this and parents will be saying this is what I'm worried about um and expectations what you're hoping that we can do for you and usually the answer to that is, I want to get better or I want the pain to go away, etcetera. A lot of pediatric history taking is trying to reassure parents as well, So a lot of people come to things like any and all they really need is reassurance. Um Not no, I mean a lot of times that's what they need they need reassurance to say that this is everything's correct. This can happen with children especially things like first time parents, so I see is a good way to kind of approach that and then closing the consultation, so doing a quick summary just to say. So currently, if I'm wrong, so you've come in today because blah, blah, blah blah um is that does that sound about right, have I missed anything is there anything else that you'd like to tell me and that finishes consultation fine, So the next thing I'm going to talk about is the newborn baby examination so that was just a quick um run through of questions to ask um in a pediatric history. Obviously, you have to tailor the questions to the presentation, governor, pain, um vomiting, diarrhea or cough. Um you know her limbs, etcetera. You want to focus the questions to that, but that's kind of the basic structure of things that you should cover. No pediatric history is very similar. Um There's just some more focused on some certain aspects, and just a bit more focused on sort of pregnancy and neonatal history as well, so the new um if there's any questions again just pop them in the chat, we will move on to the newborn baby examination, so the newborn baby examination is a part of a lot of so the final examinations in medical schools here as well and a lot of medical schools include or can include the newborn or the night p examination um their finals, uh you might be asked to do that in hospital, usually on pediatrics um Then you can also have something called the six week maybe examination, which is done by the gps or 6 to 8 weeks um Essentially all they do is the same as what we're doing here, but they do it 68 weeks later, so it's a newborn baby examination so just a bit of background about it, so it usually needs to be done within 72 hours of birth and not before six hours, um not sort of before six hours, so you have to do it post six hours of birth, but within 72 hours needs to be done by a qualified practitioner, so usually doctors or midwives have been qualified to do have been trained to do the newborn examination and the purpose essentially is to ensure that there's no sort of congenital abnormalities. If there are any appropriate referrals that need to be made to provide reassurance to the parents. To say everything's gone well. I think baby is fine um and also very important to note it into mark or bruises on the baby, which can be very important um in later life in terms of sort of safeguarding, so say if um it can happen unfortunately with children, so say if a child presents two or eight week old or a 10 week old, presents um to gp with their parents and they've got some um bruising uh and you're not sure whether they've had that since birth, they can look at the newborn baby. Examination is it and see yeah this is documented when they were born, um that this this mark I wanna say bruising this mark was present at birth. Um It's not something new, so it's not something to be particularly concerned about, whereas if it's not documented that any mark from the body um not documented then. um If the safe the same child presents two g. P, and they've got this mark and there's a bit more concerning where did this mark come from and then we don't have to unnecessarily go down sort of the safeguarding where or appropriately go down the safeguarding way. So, essentially it's very important to put document any sort of marks that you see on the child to have a quick sort of look while you're doing the examination to see if they were seeing your birth marks when you use it or anything like that. Um so introduction, so ideally what what I tried to do when I was before I was doing all these newborn baby examinations and um you do a lot of them a lot of them, especially in pediatrics, especially as um so the junior doctors, the that's essentially kind of what you have to do a lot um So before you go and speak to the parents, I really try and read the mom's labor notes prior to seeing the family, so um see how how they've usually they have like a summary. I don't know if every hospital will but mostly most of the time they have a summary. Um uh It's sort of the summary of the labor so what gestation they were what was the heads of conference, what was their weight when they were born um and you can read in the mom's notes as well. Mom has any conditions, is she taking regular medications, Is there anything that runs in the family, just have a quick run through of that, So you you're a bit more informed before you go speak to the parents. Again, some of the things wash your hands were probably PPE and introduce yourself to to the parent and explain what you will be doing so. I usually say um a lot of parents are already aware of this because the midwife tell them, uh but I just say I'm just going to be doing a quick head to toe examination of your baby just to see if I can there's anything abnormal usually, I don't discover anything but if there is then we'll let you know um And essentially most the parents were absolutely fine with that. They actually they actually prefer it because they get a bit of reassurance as well, um confirm the child's name and the date and time of birth um And then just gain consent as well so that's important um is part of the, in the uk, we have this national nippy um document or the system which is available is national and it's available online and gaining consent is one part of it, so at the top, it says have you gained uh consent from the band to do this. Sometimes parents can say no they have uh capacity and therefore they have the right to do so if they want to um that's another discussion, but most time obviously people will say absolutely fine and now this can be done in the parents, sort of parent bedside, or it can they can take the child to a better little room and you want to ideally have like a good uh room that's lit up quite well to see any change to the color of the skin and things um. And then so say if you want to take them to a different room, let the parent know, ask, ask that consent and ask them if they'd like to join. Um Parents is kind of like a 50 50 split. Sometimes parents will say yes, I'd like to come with or sometimes will be like no it's fine, it can go, examine them. I'll take a little bit of a break um the horrid life of childbirth, and they want to just have a bit of a sleep while you go, do that, which is absolutely fine, So questions to ask the parent before you take the child away is or start examining the child. Were there any complications, any prenatal so, antenatal complications, um any sort of problems during the scans um any concerns that were brought up at the time of your scans, any complications during the pregnancy, so were they born by emergency C section. What was the reason as to why they were born by emergency C section. Sometimes they'll know sometimes they won't um did, um is the mom on any antibiotics currently, so are they on iv antibiotics a lot a lot of times, there's a certain criteria and that can change from hospital to hospital on. When a newborn baby needs to be screened for sepsis. One of the factors can be mom maternal sepsis so a lot of time, when around sort of the, so, the I guess just before the pregnancy just before, sorry, the delivery or around the time of delivery. If mom is given IV antibiotics, uh they're spiked a temperature and you're thinking do they have cancer or sorry not because they they have sepsis, sorry, do they have sepsis and uh they've been treated by iV antibiotics that can be a sort of a part in as to whether you treat the child with some antibiotics. That's why you treat the child x sepsis, but it depends on on the hospital you're at and the the categories of the criteria that you have to fail two for a child to be requiring iV antibiotics can differ from hospitals, hospital, but that's a question you want to ask. Um sometimes mom will will know sometimes they might not um and also any medications were taken throughout the pregnancy, um Do they have any other medical conditions that they're aware of mean breech presentation, so breech at 36 weeks gestation or at delivery, requires ultrasound of the hips to rule out things like d. D. H, the development of a dysplasia of the hip, any past medical history, mom or dad and is there anything from any sort of significant significant family history. So any problems, I usually say any problems with the eyes, the ears, the hips, the heart, or kidneys that you're aware of that's run from childhood, so a lot of parents will say yes my grandma had problems with their heart than it's like what I'm more concerned about anything that ran from childhood to I don't heard rather than something that's developed later on in life and then questions about the newborn, how are you feeding them that's another question that you have to another sort of answer that you have to put in the night p. National system, So the breast fed bottle fair are you kind of doing a bit of both. Um As you plan on breast feeding them throughout the or exclusively breast feeding them or do you really do bit of exclusive bit of breast feeding, topping them up the formula um and then are they feeding well at the moment um or have they passed your in and have they passed meconium. So that's the question I think a lot of places, won't let you won't let the mom um and the baby so and leave the hospital. If the baby hasn't passed urine as well, so that's quite important to ask a lot of children as well, will have hearing tests um in the hospital um. So quick question to ask as well is, have they had the hearing test have they passed, um but it doesn't have to be done in the hospital. It can be done as an outpatient as well, but a lot of children will do that's questions. You ask parents and then you take move on to the actual examination, so first of all you want to inspect so just see what the colors like, are they quite pale, do their looks. I knows their lips look blue um or do they look jaundice, so they have a yellowish tinge their skin a lot of times with newborns um just being yellow um It's not the only sign of journalists sometimes it can be quite red and quite plethoric, so essentially they look pretty pretty red now, especially sort of caucasian, maybe to look quite red um Then you might ask the midwives just say have we checked the child, so joined this um in darker skin children you kind of look at the sclera and see do they look a bit more yellow from that side or again do they look pale, look at their mouth. Do they look a bit more blue um to see any sign of cyanosis, what's their posture like what's their turn are. They kind of moving around wriggling around as normal and then you kind of lift them up do they kind of um do they look at is there sort of turn quite floppy or are they are, they're a bit more so amenable question will it be possible to have slides after the presentation. I think this presentation recorded, so you can have a look at it, I'm not 100% sure, but I think we can do that, but it will be recorded anyway, so you can watch this back later um any visible birth marks on the children on the chart, so again like I said it's very important to uh document any marks on the child um on the, on the, on the, on the nypd examination, So things like trauma from birth and instrument from the sort of instrumentals deliveries do they have any lacerations on the skin. Uh things like port wine stain so that's on the bottom right and uh kind of there's a photo there. Um they kind of usually present on the face and they don't tend to go away. They can be associated with other conditions such as sturge Weber syndrome and the clip extrano syndrome, So you want to maybe look into that a little bit more so we'll send them for investigation. Do they have any hemangiomas, so essentially have any red lumps which blood vessels now. they can get bigger over time, and then they start to shrink. Um If they are sort of affecting around the eyes, if they're affecting the vision, if they're affecting them, if they're sort of around the mouth and affecting their breathing or they're affecting their feeding, then you can have them surgically removed a lot of times. Parents will say I don't want to have it for aesthetic reasons, but it's not actually causing them any difficulties in terms of the vision, breathing, or feeling like, I said. Um you can still refer that to plastic surgeons, I don't know what the if they'd actually be keen, removing it just for aesthetic aesthetic reasons, and then things like salmon patches that can be common well relatively common as well um they tend to fade by the age of two yep and things like millions. So a lot of babies were born with just little white spots on their face, very very common baby, acne, very common, uh erythema toxic um Also it's extremely common on the um uh that you should just resolve spontaneously um. And then again just have a quick look at their face. They have any dysmorphic features uh things like epic catholic folds which associate with Down syndrome, any sort of facial symmetry, thinking of uh sort of facial nerve palsy as a result of instrumentals delivery. Um If you are considering, all of these is best, just get you seen as and what often just have a chat with them especially if you're thinking any sort of features of downs and things like that, So then you essentially you didn't head to toe examination now. I'll go through the examination as through a head to toe exam, but the newborn baby examination is very opportunistic, So essentially you basically try and do it as try to take your opportunities as you can, so if the child is quite settled and they are crying, not crying, they're or they're sleeping or they're kind of, they're not essentially they're not crying and screaming that the longer that you can just take that time to just have a quick listen to their their chest because once you start fiddling with them. Once you start messing around, in the sense that you're kind of looking at their head, If they're moving their fingers kind of having a look at their hands and feeling sort of looking at their fingers. They'll start crying. They'll start to scream and then kind of settling them again, it can be a bit difficult and then you lose the opportunity to listen to their lungs and listen to the heart, so um I usually try to do it like head to toe bob vesely if there was a moment where it was more appropriate just to quickly listen to there, ask will take their loans or the heart would usually use the opportunity to do so, but we'll go through it head to toe, so head you want to look at the shape is there sort of inspects of the cranial sutures as well, is there any bruising, any sort of human termers which can occur. Um It can be as a result of the motor delivery, but the difference there's kind of two things that you see when you see bruising is that K follow hematoma or kaputs secundum, so the difference between is cephalohematoma um usually bound right They don't cross the suture line essentially, but it's important to document that um and it's also important to measure their beauty. Reuben levels because that can cause jaundice and kaputs gets a condom similar um but they tend to cross the suture lines and they tend to resolve by themselves front tunnel, so the soft so they're soft support essentially, are they soft, is it flat, is it's sunken or is it bulging, so some can would indicate that they're quite dehydrated bulging. You think you have increased cranials or intracranial pressures, and it makes sure you do their heads conference and document that as well um then moving on to the eyes, so assess for fund or reflex, it used to be called the red reflex, but it doesn't necessarily have to be red, so that's why they changed it to bundle reflex, so you turn off the lights, makes you have a dark room and you look into their eyes um So, with the funders and sort of the check in essentially for a red orange pupil and it can be red or orange. In sort of lighter skinned children and darker skin children can appear as yellow, white or even blue. If there is an absence in the reflex, or if it's completely white, so you're gonna be worried about getting a blastoma uh so that needs an immediate referral to ophthalmology, so you can see on the top right that's just a normal um fungal reflex and then in the sort of the photo on the left and you can see sort of a white got is essentially showing you retinoblastoma got very white um fungal reflex um and an absent one in the left eye as well. So you want to refer that to ophthalmology is having look at these, so the normal appearance is there any asymmetry, so are they quite low down. Again thinking of down syndrome, are there any skin tags or any pits uh They can be associated with a lot of chromosome abnormalities, so it's important to document that and just inform one of the seniors, you know what I want to you might want to do further investigations, any genetics, etcetera uh and like I said if they had a hearing test yet. Mouth and palate um so essentially checking for any cleft of the heart or soft, hard or soft palate, so checking for cleft lip or palate now a good tip When you're examining children is if you will obviously have gloves on um and it will be sort of sterile you have you wash your hands and you've got you've got clean hands and glove a good um tip is essentially to do multiple things at once, so you're basically what we'll do is um pop your little finger in the baby's mouth and they will instinctively start sucking so that's one of their reflexes, so you check on their reflexes, reflexes, so that's their second reflex one that will help you check the reflex, too, you can feel the, the hard palate as well rather than having to open their mouth and using your tongue depressed to have a quick look you can have a feel to see if there's anything abnormal in them and also, three, it'll be quite soothing for the childhood. They'll stop screaming essentially because they'll be thinking they're feeding um So you can do sort of three in one go ideally if you can so if you can have a tongue depressor and using a torch, have a look at the inside of their sort the hard palate to see if you can see abnormalities that's um the most ideal weight sure and then moving down to the neck and the clavicles do. They have any webs, um sort of webbing of the neck um that can be associate Returner syndrome, any lumps a lot of children can have things like cystic hygroma as which is sort of thesis that form out on the side of the um the next it's a document band and get sort of a senior help on that, any fractures um have they got uh so any sort of clavicular fractures do they have a symmetry on sort of their body, kind of the clavicles in the neck area that can occur in things like shoulder dystocia, move it onto an expert so upper limbs um so let's just say inspect not insect you have inspect their fingers so essentially important to count the morphine fingers as well, do they have the right number or do that polydactyly, have a look at their palms to see if they have a single palmer crease or double palm a crease, so a single palmer creases associated with down syndrome, double coral creases no more, and then moving up to their chest. Um So inspect the chest so check, take their respiratory rate a normal is a renewable movies about 40 to 60 rest per minute worker breathing either working hard to do they have intercourse source of costing recessions, so things like can you see their ribs from the outside, can you see them sucking in um in there sort of the term me do they have any tricky well tug. I did have a video of it, but I don't think it works. I'm afraid, but so it's just you can youtube it. It's just that they're basically sucking things on in the trachea um. And did they have any head bobbing so they're kind of breathing, but they're also sort of head bobbing alongside. So you know, they're working quite hard um and then also just see that inspect their chest to see if they have any impact is excavatum or curren, ate them to excavating doing in, coronated protruding out um. And then you want to check their pre and post doctoral saturations as well. So usually you check their oxygen saturations um product or beige in the right hand, so you can pop it on the right wrist. Um The saturation probes is different to like the adult clip on ones. It'll be like the wraparound ones um and the post up till can do on any limbs. I tend to just use the left leg left foot um and you have the post uh doctor uh oxygen saturations there, So if there's it should be above 95% on both sides, and the difference should be within 3% of each other, if there's any abnormalities, you're thinking of things like cooptation of the aorta so that can be a referral to Cardio as well have a listen to their lungs. Any added sounds listen to their hearts do, they have any murmurs, murmurs can be very very common in a newborn baby um just because of the anatomy of their heart um But if you are concerned, you can always refer to cardio or speak to your senior and see what they suggest like. I said this. This examination will be essentially done again at 6 to 8 weeks of life in the community with the g. P, so if they have an innocent murmur and that tends to things like p. D. A. Um if that's resolved by six, date that can resolve by 6 to 8 weeks time without any sort of surgical intervention or any medical intervention required. Um And then heart rate as well as it normally should be about 1 20 to 1 15 a newborn baby and then moving on to the abdomen, so again initial inspection is there any distension. Uh umbilical caused um does it look healthy, doesn't look quite infected, is it red, is only sort of discharge coming from it and are there any obvious hernias and this only you can see on the picture on the, on the, on the photograph on the slide that there's an umbilical hernia that and then you just wanna quickly palpate and have the feel of the tummy. Um If there's a is there any obvious organomegaly, so whenever should be sort of two centimeters below the costal margin. Um you'd be thinking if they have any enlarged sort of can live uh spleen, etcetera, you shouldn't be able to pull out the kidneys as well. Actually if you can block the kidneys in the back, you might be thinking where do they have polycystic kidneys, but you shouldn't you shouldn't be able to, but if you do then that's concerning, then moving down to sort of genitalia, so initially does it look normal, is there a sort of any ambiguity to it. If there's ambiguity might be thinking of things like congenital adrenal hyperplasia, um but does it just look standard and things to look out from mail and um obviously slightly different so with males. She wanted to look out for the position of the urethra meatus thinking of hypospadias um Any testicular swelling too. They have any hydro, seals um in sort of fluid collection there and then palpate the squirt in to check whether the testes have distended, distended. Um They can one of them usually can be a little bit higher than the other one, and that's fine that can have routine follow up, and we'll usually descend by, by the time 68 weeks, when they have their next check if there bilaterally undescended testes and that needs a referral to urology needs to be further investigated with females, obviously again same thing so does it look normal um inspect the labia, or so the clitoris is there any abnormal discharge or bleeding coming from the vagina um and that can be normal in newborn babies. That's just a withdrawal sort of the they've been exposed to maternal estrogen during pregnancy so that can happen and that is not always alarm bells moving down to the lower legs. Um You want again similar things with the hands like the hands and the feet, so you want to count their toes, any edema in sort of their feet, do they look quite swollen. How we think in cardiac failure, renal failure, assess their tone and movement so they sort of quite rigid or they're quite floppy um And make sure you palpate the femoral pulses as well. Again, this necessarily documented on the nine p examination are the femoral pulses present or not absent from reporters. Again can indicate cooptation of the aorta. This can be really really difficult. In babies. I won't know so uh from reporters can be very difficult, especially if they're crying, they're moving around a lot so sometimes I mean you can try your best to kind of settle them a little bit um It comes with practice. I would say um or you can try the the sort of the little finger in their mouth trick to get them a little bit more settled. Um I mean if you've done like the pre and post doctoral saturations and they're fine. There is a site level of sort of comfortable you'll be a bit more you'll be less concerned about cooptation because you know that the blood flow is going around, um but if you try and feel the femoral pulses can, ideally you should be able to uh pop ate those as well and then we're doing some special tests on hips, so the borrowers test um So essentially you can see that on the picture on the right, so essentially you bring the hips. You add upped the hips and you pop your fingers at the back and then you send of this of the hip and you push down you pushed posteriorly. You're trying to essentially see whether you can posteriorly dislocate the hip. It looks painful, So a good thing to say to parents is this looks painful, but it isn't for the child um and you basically trying to see if you can dislocate the hip and it is very obvious it's not like a subtle thing. It's very clunk, you can feel it going backwards um and then you can do the auto Lonnie test which is to essentially confirm that there has been a dislocation of the hip. So that is essentially when you flex the hip with the index fingers on the back of the joint of the hip and apply pressure sort of upwards to see again. Can you hear any clunks, so you do the auto Lonnie test to confirm the findings of the barlow test. Obviously, if you have any positive findings need to refer to orthopedics yeah and ultrasound, etcetera, and then turn them turn the child over and inspect their back and spine inspect their spine, is there any scoliosis. Um any sort of hair tell source, able pits that kind of present in neural tube defects, which are spinal bifida, any birthmarks as well, so make sure you expect the whole body so you want to get the child off their baby grow. You want to see them essentially be able to see all the entire skin to see if there's any sort of markings there at all. And then you want to just inspect the anus as well, so is the anus patent um and have the past makoni until that should be passed within the 1st 24 hours of life, if not a bit of a red flag and pulled up further investigation as well, and then you want to finish with reflexes again. I had a video here, but I don't think that will work. I'm afraid, so the powder grasp essentially is when you um give something to the child. It can just be a finger and they'll they'll grab onto it um and then the sucking reflex again or anything that switches this sort there hard palate at the top of their mouth. They'll start sucking on, so you can do that like I said with the finger in the mouth and then the more of a reflex um definitely try and do this as well, So, essentially warn the parents that you are going to do this before you do this because parents can get concerned that you're going to drop the child, doesn't necessarily have to be so what you can do is you can sit the kid child up like like so in the video, you can see the picture them and essentially drop them down to the back of their hand back of your hands. Um you can do that set up like this or you can hold the child, so I used to hold the child in my hands of like this kind of here and then drop them, have this at my second hands or lower down and drop them from sort of not you know, dropping them from high distance from slow district and you see they're essentially their arms, will, so of extent and fingers will extend to. They'll go like this with their vietnam and the start crying. Um A positive morrow is um good asymmetry, um May so if they say if they with their one hand, they're doing, it's all one side of their limbs or um one side of their feet, they might indicate with hemiparesis or brachial plexus injuries as well or a factual clavicle. So those things to look out for that's right um and that's it really complete the examination, so share the findings of the parents, so say just let them know what you found everything's fine, everything's um or the examination seems to be absolutely fine your child's okay um or if there's anything that you found you just say that this is something that we need to investigate further um and then document everything that you've son the scene, and everything that you examined. So there's a national my p online system and the uk not cover say so might be like I said National Influant physical examination, it's a national online system um and you to put document everything in that so that should be available um nationally and make sure you document everything clearly on there including any sort of marks and the skin and your birth marks and you kind of usually don't print three copies. One goes to the patient, one goes to the midwives and then gets to parents, but so that is essentially the end of the presentation. So like I said everything is very opportunistic in the examination you try and get as much as you can before the screaming crying starts, so things that you need to listen to and things like that try and do that as soon as possible um trying to get their saturations and things when they're a bit more settled and heart rate. Of course they're a bit more settled. They want it to be falsely elevated because they're crying their lungs out um and but try and get sort of through the head to toe um force of head to toe examination um and the more you practice the better it will get essentially um so that's essentially it uh is there any questions at all just put them in the chart there is and like I said this will this will be recorded, so you can watch it back bit later as well. If you need to um and things that reflexes and things you can just youtube. I did have uh a video four, um but unfortunately didn't work um a little bit like this. It just comes with practice as well, the more I do, the quicker most likely you become better. I'm gonna send us feedback form in the I suggest well just if people can just click on that link and just provide some feedback that be, are useful. It's got a couple minutes if anyone wants to ask confessions. Hopefully that was much too much information, but hopefully that made all made sense so receiving the slide. Um I'm not 100% sure, I think like I said this will be available um to watch back, but I will just check if the slides will be available, but we can try and do that for sure, let me just check just a moment, yeah so it will be available. Um I think it will just be on sort of a medal platform from what I've been told in the moment, but they should be available um It'll just be on the once we sign out of this um presentation itself will be recorded, You can have a look back and then you can go through all the slides there as well. I hope that answers the question. I don't know if the physical copy of the slides. I think I'm not sure if the physical copy of the slides will be available, but the recording will be uh. I've been told that the physical slides will be also available, so okay, okay, so um I think I've also been just told that we can send the slides to the attendees, attendees as well through email, brilliant ok, so what