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Hello, welcome everyone. I can see we've got 17 people in the room. Uh So yeah, welcome to the session. So I think we'll just give it another minute or so. Um And then we'll get started as there's quite a bit to cover. But yeah, thanks for joining everyone, right? 7 O2. I feel like we'll um make a start um as there's quite a bit to cover, but this will, this is being recorded. So, um after the session, anyone could basically access it if they just go on the recordings. But um so yes, I'll start our slides then. So, welcome to today's session. So today, um we are teaching pediatrics and as we are part one, we'll cover some more topics in part two. So I'm Vicky, one of a Nephron Doctor Eastbourne. And we also have ti I'm Tess and I work at Con Hospital. So, yeah, so, um let's get started. So just before we start a little bit about our organization. So Thursday 15 is basically the name of the um the final series and basically we try and base our sessions around MC QS. Um So we'll start off the session by doing 13 MC QS. Um, and we'll then cover all the answers at the end. Um We're doing them on Thursdays, uh, hence the name but also on Tuesdays as well because there's quite a few topics to cover, um, under the umbrella of finals slash also relevant for any other year group really. Um, but overall, our overall organization is called Med Tick Teaching. We also run um, like prescribing safety assessment courses. Um and we have plans for other types of sessions as well, but the main ones are the prescribing and the, the final series. So what are we actually gonna cover in today's session? So the main topics today are respiratory. So we're gonna do a bit of revision over which causes the shortness of breath, uh wheeze cough, stridor then in terms of abdominal stuff, um we're gonna look at more of the acute side of the abdominal pain, um and vomiting differentials, which I know it doesn't sound like a lot. But actually I think it's a really, really important um area to, to get right cos it's very, all of these topics are very high yield and they will also cover a bit of neuro um looking at funny times and headache and to the next so onto our MC QS part of the session. Um Tess how of how actually, how long are the, are we gonna time them for, for an age on this? I think last time we did about a minute per question. But ok, so we're gonna time you a minute per question. So if you just grab a pen and paper or you can type on your phone as well, so just get ready. Um We're gonna just go through each of the questions and we'll switch after a minute, but don't worry if you can't come up with an answer, we're gonna go through it all at the end, just give it your best shot. But it just means that we get the session moving and cover things. So without further ado everyone's ready to get started. Um, so get my timer ready. OK. And this is the first question. So time is starting now and I'm moving on to the next question. Second minute's up, moving on to the next question. Moving on again. Now on to question five, nearly halfway through, onto the next. OK. We're halfway through now, next question clearly there on to question nine to question 10, question 11. Very nearly there. Next question. OK. And last question. OK. And that is time. Well done. Smashed it. Thanks for bearing with. So I think what we'll do at this point then, um is go through the answers. But yeah, have a breather and f get you through all those. Um But yeah, test if you wanna take it away with the, um, the first explanations. Absolutely. Um So what we'll do is basically if people can just put their answers in the group chat. Um, and then we'll discuss, um, we're gonna do questions one and two together because they're both about sort of a wheezy short of breath, child. Um Don't worry if you've got the wrong answers, that's the whole point of this talk. If you knew everything, there'd be no point doing it. Um So yeah. Uh can we go to the next slide? What diagnoses have people got for this, for this question? Any suggestions for what they think is happening? OK. We've got lots of ease. So viral induced. Wheeze. OK. So just click on the next slide for me. Um Yeah, absolutely. We'll talk about why it is. Um But the sort of the symptoms and the fact that she's got these sort of episodes that are where she's well in between them is very um sort of typical of your viral induced. Wheeze. So if you go to Quest, we go to question two. Um Here it's looking at again a wheeze and shortness of breath child and what's the most appropriate treatment for this case? So you haven't got any ideas, what, what they think's going on and what, what, how they treat it. So lots of Ds, so the slightly lower dose I am adrenaline. Um Here's the next slide. Um So that's absolutely correct. Um As you clearly got here, this is a case of um out of hospital anaphylaxis probably caused by sort of something in the garden maybe a bee sting or something. Um And she's got quite a strong, has like atopic uh uh history, um, in the family. So she's likely to have her own allergies. Um, the rash and the swollen limp make that more likely than something like asthma. Um And based on her age, that's the right dose. Um So if we just go to the next slide, so on the slide, I've just summarized sort of differences between asthma, viral induced wheeze and bronchiolitis. Um There's quite a lot of overlap, both in the pathophysiology and the sort of presentation. So bronchiolitis is the, the smaller Children. Um it's got sort of a cough, poor feeding. Um and it lasts up to 7-Up to 10 days and it's actually usually caused specifically by um the RSV virus, um which in adults will just cause um sort of cold like symptoms. But because the in babies, they have much smaller um airways, um any kind of sort of constriction is gonna cause this wheeze and crackle for them. So we don't really notice it. Now with our big airways, um viral induced wheeze is seen in slightly older Children. It's very, very similar in presentation and management um to asthma, but it's always associated with infection and they are usually well in between. So they don't have um sort of other triggers like exercising allergens, they don't have a, a cough that's worse in the morning, et cetera. Um And with asthma you need to be sort of over five to be able to do the, the sort of spirometry and peak clothings required for, um, required for diagnosis. Ok. Um, bronchiolitis is managed slightly differently to, um, viral induced wheeze and asthma. Um, mostly it's sort of self resolving and can just have supportive care. So give them small and frequent feeds because they're gonna struggle to breathe through their nose whilst they're eating, you give them saline nasal drops to help and always safety net, the parents um to bring them back if there's any issues, but sometimes you might have to admit them to hospital for oxygen, some nutritional support if they're not able to feed up a sort of 50% of their normal um intake. Other reasons to admit is if they have risk factors for very severe bronchiolitis. So premature babies, babies with underlying lung or heart conditions are at higher risk of getting more unwell. Um And generally if the parents are worried, we admit babies with bronchitis, um just sort of to be on the safe side. So if we go to the next page, um so this is just a, a quick overview of how we manage acute asthma, which like I say is actually similar for the way we treat viral induced wheeze in a community, you might only have salbutamol inhalers. Um You need to get that with a spacer and then get into hospital if that's not controlling their symptoms. After 10 puffs in A&E we can give um bronchodilators via um nebulizers. So something like salbutamol and then ipratropium is usually added and then we can give steroids as well earlier. It's important to give them early on in acute asthma. Um I've just popped the prednisoLONE doses by age on the screen there. It can be really useful for your exams to remember to learn the sort of acute, severe life and life threatening criteria because they do like to ask things like what is the severity of this asthma attack? Um But generally you're gonna want to assess the the new score, the peak flow peak flow is very important for the same severity. You're gonna listen for wheeze, you're gonna do an ABG. Um And if that CO2 is, is normalizing, that's, that's life threatening. Ok. Any questions about asthma before we move on to anaphylaxis. Um in answer to the question in the chat, yes, I think you do get access to the slides or, or a recording after this if you fill in the feedback. Ok. So let's move on to anaphylaxis now. Brilliant. So anaphylaxis can often be conf confused with things like asthma or um if you're looking at the sort of the BP, people might think that the patient is septic. Um But you're gonna see wheeze, possibly itching and hives, swelling of the lips, especially uh in proper anaphylaxis. You've got this rapid onset with airway breathing and circulation compromises a do not miss differential. You need to get senior help immediately lie them down, improving blood supply to the brain, remove any triggers. So if it's an antibiotic, that's sort of running into the cannula detach that and then the treatment is IM adrenaline. So, in the question, I think she was an eight year old. So that puts her in the 6 to 11 category where you give naught 0.3 mg of im adrenaline. You're also wanna gonna wanna give them chlorphenamine and hydrocortisone. Um And you keep them in for observation about about 6 to 12 hours because they can have a biphasic reaction where they go back into anaphylaxis. Ok? And then when a child is discharged, um they need to be seen like followed up um by both their GP and also in the pediatric outpatient clinic and they need to be given education. So spotting the signs how to avoid allergens using an EpiPen and um possibly sort of how to do pediatric B LS. Ok. So I think that's everything for anaphylaxis that I wanted to cover. So let's move on to question three. So here we've got a coughing child, we've moved on from wheeze to coughing fits. Has anyone got any ideas what this one, what the treatment might be here or what the diagnosis is and therefore the treatment. So we've got CCC and someone said it's whooping cough. Therefore, you use a macrolide such as Clarithromycin. Brilliant So if we go into the next slide, it absolutely is whipping off. But if we go on to the next slide, um, you'll see why no medication is required in this circumstance. Um So we'll talk about it about what we can cough is in a second. But basically, this patient has had the symptoms for six weeks. So it's not within 21 days of symptom onset and therefore we don't give the antibiotics, but otherwise it would absolutely be the correct answer. Um So if you just go back one slide, so she's got these coughing bouts, coughing so, so much she's, she's vomiting. Um, but it's been going on six weeks. So actually, there's, there's nothing to do, um sort of medication wise in this case. Um So if you just go forwards again, whooping cough, um, is caused by the pertussis, um, bacteria, usually you're vaccinated, but this patient didn't have a childhood vaccines and it can give you these sort of, um, paroxysm also is sudden onset coughing bouts with this very loud inspiratory roop noise. Um, and they might cough so hard that they vomit or they faint or, or in infants, they might have apneas, ok. It can last 23 months. Um, and it's highly contagious. So, um, it's a notifiable disease is diagnosed, um based on the symptoms, having them for more than 14 days and also a positive swab and school exclusion is either 48 hours from when you start antibiotics if you're going to give them or 21 days from symptom onset. So this child can go back to school. Um, if she hasn't been there, um, if it's a child under six months, we need to admit them because it can make babies um, very ill. Ok. We will cover um, some other causes of cough. Um, a little bit later on like croup. But if we just go to the next slide, I've just got a summary of chronic asthma management. Um So we've covered covered sort of the acute asthma, but chronic asthma patients are most likely sort of symptom is that they're gonna have a cough. Um and maybe a bit of increased work of breathing with exercise, that kind of thing. Diagnosis is hard to make in Children under five. So often we can just like treat them if we suspect it and observe whether that improves their symptoms. But for Children over five, they should be able to engage with spirometry. Um and see if it's reversible with bronchodilators or sometimes you can do um feno um testing um in that, that black box at the bottom, I've just put the sort of the criteria. So it needs to, on spirometry, it needs to show obstruction that is reversible. OK? If you do decide to give um a child an inhaler, it's important that they actually have the correct inhaler technique and that they're given a spacer. And if it doesn't seem to be working. You wait 4 to 8 weeks before you sort of move up the ladder. Um I'll put the two ladders here, so there's um sort of one ladder for the under fives and one for over fives, which is pretty much the same as the adult um ladder. Um It's something to learn. It's good to you learn examples of brands as well because we always prescribe inhalers as, as sort of the actual brand as well as the constituents. Um If there are the GP can make these diagnoses, although it's that you're usually um referred to a pediatrician. Um you might need specialist advice or additional investigation if the diagnosis is unclear or they're not responding as expected to asthma treatment or if there's a severe life threatening asthma attack. Um they always need to be seen in follow up clinic by pediatricians. That's, yeah. Um you move up a step in the ladder just like adults if they're using the relie reliever inhaler three or more times um within a week. Um and you can move back down to a lower step on the ladder to find the lowest controlling therapy because we obviously don't wanna give kids more medications than they need. Ok. Um If we just move on to the next slide, so another cause of of cough that we're covering here is pneumonia. Um So kids can absolutely get chest infections like adults. The causes are slightly different in terms of like, what's most common for kids, but the most common is still is strep pneumonia. Um, and I've popped some other ones on here, including some viruses if they are under five, they are at risk of getting more and well, so we should advise parents to go 111. Um, and if they're exposed to smoking or they have a sort of past medical history that puts them more at risk of getting on. Well, they should be seen in the pediatric assessment unit. Symptoms are very similar um to the symptoms you get in adults, but you might also see things like sweating, which is feeding irritability, wet n uh dry nappies, sorry. If someone's getting repeat like recurrent chest infections um in a child, you're gonna do a number of investigations including chest X ray to look for structural abnormalities or foreign bodies or potentially even a cancer. You're gonna test them for antibody deficiencies. Um You're gonna test, you can also test them for something called IG class switch recombination deficiency, which is basically where they can't form long term immunity to pathogens. You might consider doing a sweat test to test for cystic fibrosis, which we'll cover in a bit. Um And you can also consider an HIV test. Ok. So if we move on to the next slide, um So directly linked to my last point, this is a case of a child with cystic fibrosis. The parents are both carriers. And this is asking what's the chance of them having another child with cystic fibrosis? Ee Yeah, you guys are smashing it. Um So if you just go on two slides on for me, yeah. So they are, it's a an autosomal recessive disease. So there's a 25% chance of two carrier parents having a an affected child. Um, it affects multiple systems. We often think about it in just sort of the context of the respiratory problems. So, recurrent infections, bronchiectasis, et cetera. But it's also gonna affect things like the pancreas causing pancreatic insufficiency symptoms, including diabetes and failure to thrive. It could affect the abdomen and the biliary tree causing obstruction stones or a newborn meconium ileus or rectal prolapse. And unfortunately, as the child becomes older, it can become apparent that the reproductive organs are factored to um resulting in reduced fertility. Basically, you have a mutation that affects your chloride and water movement in it, in and out of cells and that causes these thick secretions um in the sweat glands. It also um results in very sort of chloride, heavy sweat, which is why we can do the sweat test to diagnose. Um but it's also part of the newborn, newborn screening heel, prick blood test. Um So often cases are picked up very early on. Um but if not, we can do sweat test and then things like genetic tests can be done for the parents as well. Other investigations, um, are sort of looking at these, these key problems that, um, cystic fibrosis can cause. So you can look at the lung function, bloods, um, look at the pancreas, you can do fecal the last days, fasting glucose, et cetera. Um, you might, you might do some chest imaging. Um, and if you, you're worried about obstruction, you need to do some abdo imaging as well. So if we move on the next slide is about management. Um So unfortunately, you can't really, the only sort of definitive management is for the for the lung problems as a, as a a lung heart transplant. So the main, we're just trying to minimize the symptoms, minimize the impact on life. So they need annual vaccinations and regular physical exercise to keep them sort of at their peak health, so to speak. Chest physio is really important to help them clear the mucus, these thick secretions, they might need prophylactic antibiotics or um to stop these exacerbations and infections. Bronchodilators and mucolytics can also help. And then for the pancreas, if they've got pancreatic insufficiency, we need to replace the function of the pancreas, essentially with enzymes and insulin. Um Nutrition is also very important to optimize and they basically, they'll be managed by this big multidisciplinary team and they'll have two specialist um sort of visits a year. Um And every year they'll have um pulmonary function testing, chest X ray sputum cultures and diabetic screening. Ok. The big complications are massive hemoptysis or newer works, but that's not going to affect every child. Thankfully. Um Later on as the Children become older, they, they're going to need things like fertility counseling. Um cause there are, there are risks with pregnancy. Ok. So we're gonna move on to the next question now, which is, I think the last respiratory question. So this is now about a question about a child with Stridor, which is an upper airways noise. She's got hoarse voice fever. Um But news is stable and she had some Carrizal symptoms the night before. What do we think is causing this? So someone has suggested a parainfluenza, someone else has suggested de Hemophilus and someone else has suggested a, ok. So we've got a 50% split between A and D um which is good. Cos I'm about to go into the differences between the, the conditions. So if we just click next. So in this case, it's a parainfluenza and we'll talk about that. Why? That is parainfluenza causes croup and the other one D um causes epiglottitis, which um are very similar presentations often re is the bronchiolitis, one and pertussis. We talked about being whooping cough. Um So in this case, this is more likely to be croup. Um And that's because it will have these preceding crier symptoms and she's very stable at the moment and has a hoarse voice if we go on to the next slide. Um So croup is I mean, I would have given it away if I'd said barking cough. But that is often the key term they'll use in a, in an M CQ. So they both have stridor and secretions or drooling. But in croup you've got a barking cough, a hoarse voice. Whereas in acute epiglottitis, all that's muffled. Ok. And in acute epiglottitis, they're going to be very, very unwell. So II gave her a few score of zero, I think or said she was stable. Whereas if it was epiglottitis caused by h influenza type B, they'd be, they'd be unwell, they'd be tripoding. So like leaning forwards on the hands. Um and you, you wouldn't, you'd yeah, you'd hear these muffled sounds. Both of them might have a fever. So that's not super helpful. Um And like I say, croup has usually a, a prodrome before it. The affected age group is a slightly different group tends to affect slightly younger Children and you're not going to X ray these Children. But if you did, um you'd see something called the steeple sign. Um in croup and the thumb sign and epidosan, you, you shouldn't be um yeah, you, you wouldn't normally x-ray these, these Children because you need to treat them. Instead. Croup is a lot less serious. It's usually self limiting. They recover within 48 hours, but there is a risk of airway compromise. Um So it's important to involve CS keep the child as calm as possible. Do not, um, do an ent examination on for either of these cases. Um, and for the creep you're gonna give dexamethasone. Um, whereas for the epiglottitis, you're gonna give antibiotics as well as dexamethasone because it's a bacterial infection. Um, education for group is sort of stay off school while you're feb, while the child's febrile good hygiene measures. Give them paracetamol at home, comfort them, give them fluids. They don't need to inhale any, any sort of steam or have any cold medicines. Um And if they're not getting better after 48 hours or they get very noisy breathing, they need to be brought in urgently or if they sort of start struggling to breathe or they turn blue, like call an ambulance. Um In the moderate severe cases, you might also give them nebulized adrenaline. Um That would be for patients with sort of very high fevers or respirate above 60 signs of respiratory failure. Um And also if they're sort of under three months old, you're gonna be worried about them. Ok. So if we just go to the next slide, this is just the severities of croup mo moderate severe. So like I say, if it's just mild, give them or dexamethasone and send the parents home with education. But if it's moder or severe, you need to make sure that airway is gonna be protected and add nebulized adrenaline. And then if we go on to the next slide, so a final cause of Stridor might be a foreign body. This is in commonly in the NC QS. It is gonna be a younger child or someone with learning difficulties, the carer reports them playing with a small object and sudden rapid onset of choking coughing, gagging might be short of breath. Um You might hear them coughing, you might hear a Stridor on auscultation or a unilateral monophonic wheeze, they're likely to be a bit hypoxic. Um And to have diminished breath sounds on one side. Um If they are conscious and it's in the community, you encourage them to cough and you can give them some back blows. Um If that's unsuccessful, you give abdominal thrusts or if it's a less than one year old and you give them five chest compressions. Um And then if that's successful, you send them to the hospital, if that's unsuccessful or the child and the um you need to call 999 and continue doing your back blows your chest thrusts or abdomen thrusts. And if they lose consciousness, you need to start CPR. Ok. Um But if they are calm and they are ok, don't distress the crowd call all the airway, pediatric magicians to come secure the airway. Um and then you can do a chest X ray to confirm and remove the foreign body with a flexible bronchoscopy. Ok. So before we move on to neuro, has anyone got any questions about any of the rest conditions? We've just done a whistle stop tour of, if anyone thinks of anything later, go feel free to put them up. Um So if we go on to question six, so we are now in Neuro land. This is a, a child with a shaking episode or a funny turn or a seizure, whatever you want to call it. Um And that's in the context of a fever and this is the first time it's happened. No, sort of very interesting family history at all. Not a very interesting examination, slightly ACR P which fits with having a fever. So what do people think is going on? And what sort of action would they take next? Someone suggested d someone suggested that it's a febrile seizure and therefore they would give safety advice on paracetamol. Ok? Looks like the consensus is D which is exactly the answer I was going for. So if we just go on, so if we year to the next slide, um this was if you look at the febrile convulsion sort of table, this is a young child with a high fever who's had what classes as a simple febrile convulsion. So, generalized tonic chronic, that lasted only a few minutes and has happened only once. Um And because this is the case, they are unlikely to have any lasting damage. And as long as we sort of control the fever, manage any underlying infection, no further investigation is required, but you do need to give some sort of s some safety advice for parents on what to do. If there is another seizure in the future, we call febrile convulsions complex if it's, you know, a partial or focal seizure, if it lasts a long time or if it happens several times within the same illness. Um When we, when would we think about epilepsy? Um sort of, it's about the circumstances. So they'll usually have more frequent seizures, not necessarily in the setting of illness, they might have lasting neurological um symptoms afterwards. Um And there are lots of different triggers, illness, stress, alcohol, tiredness, et cetera. So if we do think it's epilepsy because they haven't got a fever or it's happened lots of times we need to investigate with eeg MRI electrolytes cultures. LP, thinking about sort of aphis meningitis differentials and then they may be started on antiepileptics or if they're in the state epilepticus. Benzodiazepine is just like for adults. Ok. We on to the next slide. Um So this is more OS related than M CQ. But if a, if a child has had a febrile convulsion and you, you're, you're confident in that from your history, um You need to explain that to the parents, reassure them and tell them if you know a seizure happens in the future, they need to stay with them, put them somewhere safe where they're not gonna injure themselves. Ideally, in the recovery position, don't put anything near their mouth and if it lasts more than five minutes, they need to call an ambulance. Um And if, if, if it's self terminating and they don't call an ambulance, they just still need to be seen by their GP ASAP. Ok. Yeah. Ok. Next question. So this is a teeny tiny baby. Now, what treatment would we like? I should say. Um I think we're in hospital in this, in this question. So we're getting some, some d suggestions here date. Yeah. Yeah. So if we go on to the next question, uh next slide, sorry. So this is a case of bacterial meningitis. We're suspecting that already from the, the history. So they're not feeling well lethargic. A bulging fontanel is, is um like a keyword to look out for in your MC Qs and she's feverish. It's a bit hard to know what's going on with a child. Like a baby with fever, often very nonspecific symptoms, just not feeding well. Um But we've done an LP as most babies would have in this situation and it's showing cloudy fluid which suggests it's bacterial. Um it's high protein and, and low glucose because the bacteria is eating the glucose essentially. So we're thinking it's a bacterial meningitis and this child is two months old. And so if we go on to the next slide, um I not put the um oh the treatments on the next slide. OK. Um So I'll just summarize the sort of key symptoms you might see here in Children versus babies. Um, you do a lumbar puncture in any baby, less than a month old who has a fever. If they're 1 to 3 months old, you do an LP if, if they're unwell with the fever. Um, and if they are less than one, if, if, if, if they've got features of serious illness, other investigations of the clinics and these signs. Um, and you'll say, yeah, when you do your lumbar puncture, you want to look at the bacterial culture, viral PCR cell count, protein and glucose. Most common causes. Um in Children are sort of meningitis and streptococcus pneumoniae. But in neonates, it's group B strep that they get from like during childbirth and in terms of viruses, it's HSV um and varicella and enterovirus. Ok. So if we go on to the next slide, this is where I've got the management. I got confused there. And so adults, I think get ceftrixone like the over three month year olds, but this was a two month year old baby, which is why we've given cefotaxime and amoxicillin as our antibiotics. And then you also want to give steroids to try and protect from neurological damage. Um And if you're considering that there's penicil penicillin resistance, you add Vancomycin that's in the hospital. If we sort of know what's going on in community, if you've got an unwell child, you need to give them Benzyl penicillin cos, that's what they have in the GP surgery and then transfer them um by ambulance. Ok. And notifying public health was actually one of the question options. That is something you need to do, but it's not the most urgent thing. Of course, because you've got an unwell baby in front of you. If it's a viral case, they often just need sort of supportive management. Um But you do want to do a viral PCR to try and determine that and then you can give a like if, if it's an appropriate infection. Um It's not super clear, but I've done a, I've, I've stolen this table from the zero to Finals website. It just summarizes bacterial versus viral. Um CSF from a lumbar puncture. Um If someone has been in prolonged, close contact with someone that has meningococcal infection in the sort of seven days before they got ill, it's i it's important to give them post exposure prophylaxis, which is usually a single dose of ciprofloxacin. Um And like um like I said, the babies, the neonates are likely to have group B strep, which is why we add in the amoxicillin. That was why that was the correct answer for this question. OK. Any questions about meningitis, we'll move on to the next question. So, question eight, this is our final neuro question. So here we've got a six year old with a headache that seems to be progressing. But otherwise, well, and we couldn't really examine him. What, what do people feel they want to do. So, a lot of people want to do e because you know your stuff very good. So, if we go to the next slide, it absolutely is. E, um, so Sumatriptan might be appropriate if it's sort of migraine type headaches. But actually in a, in a child headache is, is always almost always concerning if they're under 12, your more Children and w get tummy aches rather than headaches. So there's often something else going on. Um, and this sort of hasn't been described, um, as a migraine type headache. So I wouldn't go straight for the sumatriptans. They're well, so I, and it's been going on for over a week. So I'm not so worried about meningitis. I'm not thinking about an LP here. Um, and if we go to the next slide, we'll talk about when we do do scans. So if we just go to the next slide. Mhm. Either I have lost connection or Vicky has, oh, let me try and present what slide was it? Can people put in the chat if they can hear me? Ok, you can hear me and ca and are you guys seeing currently the pediatric headache guidelines? Amazing. Ok. I don't know what's happened there. We will carry on. So this is just taken pretty much from the nice, um, nice guidelines for pediatric headaches and also head smart, um, basically an under 12 year old with a headache. But it has any of these concerning features and needs to have same day pediatric assessment. So if it's waking them up or present in the morning, if it's getting progressively worse, like in the question, if it's triggered by coughing, sneezing, bending down, that's signs of increased intracranial pressure. Obviously, if it, the signs of meningitis or um then we're gonna be concerned about meningitis. Anything like ataxia changes in consciousness are concerning uh changes in vision, especially if they've got like a squint or unable to gaze upwards. And also in, in the context of a head injury, these patients all need the same day assessment from a pediatrician if they're under four and they have a headache, we're very worried, they need urgent neurological assessment. Um because like I say, it's not common for your smaller Children to actually get headaches in the same way that f ones get headaches all the time. Um If you are suspecting a space occupying lesion, we'll go, we'll, we'll look at that in a second. What sort of symptoms that might make you think that they should have an MRI both done and reported within a four week period. And that's the sort of guidelines. If a, a patient is having recurrent headaches, you've ruled out anything sort of sinister. Um All Children with recurrent headaches should have their BP checked and compared to sort of their age and they should have fundoscopy. So you're gonna refer those Children to. Ok. So if we go on to the next slide. Oh, I'm in charge of the slides. If we go on to the next slide, um, um, these are some symptoms that could suggest a brain tumor. It's much more likely if they have several of these signs together. So, like I say, just having a headache is less likely to be a brain tumor. But if they have a headache and move your symptoms or usual symptoms or diabetes insipidus, that's when you become sort of more suspicious. It's important to ask about all of these symptoms. Any predisposing factors like personal or family history of a known brain tumor or leukemia, early onset breast cancer in the family. Any previous radiation to the central nervous system or conditions like neurofibromatosis or tuberous sclerosis, all those can sort of predispose you to brain tumors. Um, symptoms can fluctuate and can occur in isolation or in combination, but like I said, just a headache with no red flags is rarely a brain tumor. Um, if they've got a persistent headache in an under four year old or a persistent headache that's waking them up. Um You, you do need to scan them within that four week mark. Um, unfortunately, um there are some things that can sort of contribute to diagnostic delay and those include social deprivation, no parental education, family. Um And those, those people would benefit from things like health visitor liaison services. If A GP is really suspicious, they should discuss their concerns with the pediatrician the same day. Um and refer them to a rapid access clinic. Ok. So that is, oh, I don't know what's going on with the slides, but that is um so I can move the slides. Don't worry, I'm on it. You're on, right. So that is a whistle stop tour through resp and a little bit of neuro um We didn't cover things like um what am I trying to say? Like developmental conditions um or cerebral palsy, we can cover them in, in part two if people would like. Um But now I'm gonna hand over to Vicky to do um some ado conditions. Thanks guys. Hello, sorry, thanks for bearing with. I'm not really sure what happened just then. Um but hopefully it will be smooth plain sailing from here. Um So moving on to the first question of the ABDO section. Um So can you please pop in the chat? What do you think might be going on here? So what do you think might be the most likely diagnosis of all these any answers? Stunned silence? Oh, ok. Well, we'll move on to the answer then. Um So you've got some answers in the chat. People are saying, oh, sorry. I don't know why it wasn't loading up for me. Ok, perfect. Well done. So um yeah, so that's the correct answer there. And does anyone want to tell me before I move on to next? I why out of all of these, the one factor, one actually key bit of history that makes you think um this could be um the, sorry, I just got it neonate. So, yeah. Yeah. Yeah. And specifically, um with the neonatal period, it's being preterm out of all of these, um out of all this bit of history because the bile staining um, vomit, that could be a lot of these things. Um But because they're preterm, I'd say that's especially why in this answer. Um Sorry in this question that um neck is the answer here rather than the rest. Um And then also the other key bit of information there is also the meconium passing of the meconium. Um So yeah, because she passed the meconium within 10 hours, that's normal. So I think that kind of rules out Hersh PRS there as well. Um Yeah, so let's go into a bit more detail about necrotizing into colitis. Um So I think it's quite useful condition to know about um within sort of the abdominal differentials. I suppose the key thing here um is that it happens mainly to preterm babies. Um So you can see here that your neck is an acute inflammatory disease, affecting preterm infants. It can lead to bowel necrosis, multisystem organ failure and is life threatening. So that's why actually in those answers there, sepsis was an option, but the obs weren't quite there yet in terms of sort of indicating sepsis, but it could definitely be heading that way and neck was just a bit more specific there. Um So yeah, you can see here, the stats show that neck is very rare actually in turn babies and the whole sort of process behind why that happens is quite different in uh turn babies. But yeah, 85% of neck cases um occur in infants who are premature, especially less than 32 weeks and have a low birth weight as well. So, uh in terms of what actually causes neck, um there's not really a specific answer. It's just due to a lot of different factors here and we know obviously that is associated with being preterm. Um And yeah, so I've got this little diagram here which just shows basically a whole host of different reasons. Um But I think the key takeaway point is if you see bullous vomiting in a preterm baby, just having the back of your mind neck. So in terms of typical symptoms, so things like, you know, n feed intolerance, the bilious vomiting, that's very important, distended abdomen might have fresh blood in their stool. Um And in terms of examinations, sorry, like distended abdomen again can be, can be tender, reduced, absent, bowel sounds maybe an abdominal mass, visible loops, intestinal loops and the skin. I mean, I didn't want to put a picture on here, but if you want to have a look yourself as well, just to get an idea, it looks kind of almost cellulitis like on top of the belly, if it, if it gets to the stage where we're getting peritonitis, and then obviously just systemic signs um indicating like in hemody hemodynamic instability. And actually, it is, it can be quite difficult to diagnose neck actually, as there's not really a specific s uh examination finding basically, which will help us diagnose it. Um It's just a com combination of um factors and um I think just based on the history, you'll be able to differentiate between the different differentials here. But I think it was pretty clear in that in that question that this was the most likely. Um So in terms of investigations, there's a whole host of things that you can do there. So, yeah, full blood count, CRP CBG blood culture. But I think the um really key abdominal X ray finding er is this pneumatosis intestinalis. So that's bowel gas in the sort of intramural space. And that's actually patho pneumonic forex as in if you see that it's pretty, we're pretty certain that it's neck basically. And so I've got a little image of what that looks like. So these are some um classic X ray findings that you might find in neck and examinable as well, I suppose. Um So you can see there, yeah, air under the diaphragm and that can occur. It's bowel perforation, um air in the portal tract. So I've been told it looks a bit like tree branches in the liver, um, sort of darker tree branches and then you can get distended bowel loops. And then there's that intramural area that I was talking about, which is um, very patho fic basically. So that's another key buzzword in there. Um In terms of management, it basically relies on what stage of neck and I don't feel like you should get too bogged down in this detail. I'm basically putting this here just for sort of sake of completion. So, you know what happens? But there are basically lots of different stages of neck in terms of severity and that basically determines what um management we're gonna have. Um you know, put in place. But for your own interest, if you're interested in neonatology, um this is basically how they decide um what we do. Um So yeah, we're sort of looking more at Bell stage one and stage two. So on the less severe end of things, we don't, we may not need to sort of have too uh invasive and um you know, management. So you might just involve withholding the feeds, um, some IV antibiotics and some just general systemic support once we're getting to. So stage three level where it's uh you know, maybe signs of perforation, um you may need to have this surgical intervention at this point, but hopefully you catch these before we reach that point. Um So yeah, that's basically neck in a nutshell. And I think, yeah, the key thing is just to know how to differentiate between the rest of them. Cos bullous, vomiting can mean a lot of things. Um But it's looking at the general picture, what age group are we talking about? Um And that will just help you differentiate between the rest of them. And so my next section here is basically talking about um vomiting differentials and this will be useful for the next few questions as well. So excuse for the maybe overwhelming slide here. But basically, this slide is just here to show you that it could be so many different things. Obviously, there's like gi causes in themselves, but then there's also loads of non gi causes as well. Um That could cause vomiting basically. Um So it's I think a really, really important presentation in pediatrics to get to know how to differentiate and to get in right in your exams because it's, yeah, it's just I think very examinable, very important also in real life as well. Um So yeah, this is just to give you a picture of what could be going on just to keep your differentials broad, but obviously depending on, you know, the child in front of you, um you can narrow things down a bit more easily. Um So and then, and I just thought as well. So when you're trying to differentiate between vomiting differentials, there's a few I think key points to have in your mind when you're thinking. Hm, like what could be going on here. I think a classic one is, you know, bullous or non bius. Is there blood in there? I think age of presentation is very, very, very important as well associated symptoms as well. And basically, when I was doing research for making these slides, I found a really good resource um on Peds cases will share all the resources at the end. So you can have a look yourself. And this, I thought was a really good table which sort of, er, showed what age groups and what conditions you expect at each age group. Basically. I think it's very important to have this in the back of your mind with a lot of peds, um, topics. It can, you know, it doesn't just, it's not just gi, but in any peds, topics just have in the back of your mind. What age, um, do conditions normally present at? And I think that will just help you, um, organize your thoughts because it is overwhelming peds. There's just so much to remember. Um, and then I went one step further and this table is not complete. I didn't have enough time to feel like, complete all of it, but I just thought as an idea as a starting point, um, to make your life easier when thinking about vomiting, I think a table like this um, is quite helpful because then you can just see, ok. Right. What age are we thinking? This is most common at um what are the key things that you're gonna see in the history that are gonna be able to make you differentiate between different vomiting causes quick? So, you know, is it vous, like I said, what's the stool like? Um, is there an abdominal mass or is there a really key er investigation or um imaging finding that would be like? All right, that's definitely pyloric stenosis, you know, I it can't be anything else if there's that finding on the ultrasound scan. Um So yeah, sorry, I didn't get to finish all of this table, but I thought it's most, quite a lot of information is already there. And I feel like this would be like a good starting point and you can make your own with the rest of the um vomiting kind of conditions and presentations. So, yeah, just a little idea there. Um And then this slide is just to um basically um enhance the point that, you know, with the bullous vomiting. Basically, it's quite a good indication for you to tell you where the defect is. So you can see that this diagram shows that if you get bullous vomiting, basically, it means that the problem is below the larvata, which is basically the entrance to the duodenum. So you know that the problem is below or above this line depending on um whether the vomit is bullous or not. So I just thought it's quite useful to just have the back of your mind just to help visualize where the problem is. Um Oh, sorry. And I will answer some questions in a sec. Um And here, as well as some key concerning features as well. If you see in the history, just think, right? Something's not right here. This is not just a simple uh regurgitation after food that's, you know, harmless, it's, you know, something pathological going on here. Um So I've got a question here. Would you generally expect a fever in neck? Um Not necessarily, um I think neck can definitely lead to hemodynamic instability and it can lead to infection, I suppose if there's um perforation of the bowel. Um So yeah, it can definitely lead to fever but you may not initially have the fever. Um So yeah, II don't think it's necessarily a make or break um symptom if that makes sense. But it, I think in that question as well, it helps you differentiate between sepsis and um neck because you didn't have really that high a temperature at that point. OK. I hope that all makes sense. So moving on. So this is question 10. And what do you reckon is the answer here? Try and refresh it this time. Tests. Can you see any answers coming through for some reason? I can't uh Not at the moment, not at the moment. Question, someone says the slider that moved, I can see. Question 10. That's weird. Anyone else? Can anyone else? So now it has apparently fine. Oh, it has. Oh, sorry. It's probably my dodgy internet. So, um. Oh, excellent. Yes, well done Lys smashing it. Um, so sorry, I give people a chance to also get the answer. But yes. Um, so that is the right answer that I said d um, and actually before I also go on to what we're actually talking about here. Do we have any idea what condition we're talking about here? What springs to mind? Sorry, just refreshing again. Sorry. Tess, let me know if my, um, the chat function doesn't really refresh that much on my thing. Can you just tell me if there's any answers there? Someone has suggested pyloric stenosis? Yes, well done. Excellent. So I thought I'd ask about pyloric stenosis in a different way. Um So yeah, it's, yeah. So basically, um the reason why, um you're getting this ab you know, abnormality in the blood gas is because, um, you'll be vomit, you know, the baby will be vomiting a lot. Um So that means that you lose the hydrochloric acid. Um And then this will start to impact the kidney basically. Um And that also leads to sort of hyperkalemia. So this is, would be a few, um days along basically, this kind of finding initially you would probably get the hypochloremic bit, the hy hypokalemic bit also suggests it's been going on for a few days as well because it's now starting to impact the kidneys so well done for getting the answer right. So this is another really like high yield um condition to know about. Also just again, like important to know about in life. Um So what is it? It's basically a thickening of the pyloric muscle. Um And that results in a narrowing between the stomach and the small intestine. And then as this gets narrower and narrower, it's just gonna lead to that really explosive projectile vomiting described as, you know, hitting the walls. And that's um also important in your AK is, let's say you have a a station where you ask about vomiting, you know, how, how explosive are we talking? Is it hitting the walls and that will help you differentiate between worrying and less worrying causes of the vomiting. Um in terms of how common it is, um fairly common ish and occurs more in males as well than females for some reason. Um Any risk factors, any causes again, didn't really find any clear um associations there. Um But main risk factors include being male, first born and also having a family history of pyloric stenosis. So, in terms of clinical features, so yeah, it typically presents at 4 to 6 weeks. So that also helps you differentiate, you know, what could be going on here in terms of the age, it's nonvillous. That's another key important factor. So it happens above that um anatomical point that I was talking about before. Um they'll typically present, you know, dehydrated from all the vomiting and they'll still be very hungry despite, you know, losing weight because they just can't keep anything down in terms of examination findings. So probably on pass med and all sorts of other resources. The plastic thing you'll see is an olive sized mass, which is very good for M CQ line. But I think in real life it is, can be quite difficult to actually feel. Um, but if you are going to feel it, it's probably best during when you're actually feeding them. Um, and I'll go onto that in just a sec. Um, you're more likely just to see sort of peristalsis um, of the tummy basically just, it's like a little wave. Um, but yeah, both can be quite hard to find, to be honest though. Um, so in terms of investigations you're gonna do, you're gonna test feed them with dextrose and it's at that point that you might feel the mass, um, around the pylori or you might actually see peristalsis. And in terms of ultrasound, um, you're gonna see a hypertrophy of the pyloric muscle and these are some specific, uh, numbers here to remember. I don't know if they test you specifically on that, but just so, you know, that's the criteria that they, that we're looking for. And like, like we said earlier, so the capillary blood gas would show a hypokalemic hypochloremic metabolic alkalosis because of all the vomiting, you're just losing all that chloride and then eventually it starts to impact the kidney, right? And then that's what um the ultrasound scan would look like. Um, I feel like that, you know, it's fair game, I suppose if they might show you like an ultrasound scan. Um, and hopefully be something quite obvious. Um I'm not sure how obvious I'd find this o on um, out of the blue, but if you're revising, just have this in the back of your mind that this could be like an image question as well. Um And now you've seen it, Okie Dokes. And then in terms of management, so initially, um you can sort of decompress the stomach by putting in an NG tube and then it's always good to um rehydrate correct electrolyte abnormalities before any sort of surgical procedure. But ultimately, they're going to need a surgical procedure to correct this. You know, it's, there's no other way really. Um So you're just trying to optimize them before the surgery and the surgery is called Ramstedt Pylorotomy. And that basically just opens up, uh, the narrowing. Um And I think that's as much as you'll need to know about that bit of the management. So, yeah, any questions at all at this point? If not. Uh t sorry. Can you tell me if there's any questions at the moment? None that I'm seeing? Ok. Excellent. We'll carry on then. So, moving on to question 11, any takers for the answer on this again. Sorry if I'm not seeing the answers that for some reason it's just not loading us. Um They're on, they're on any to see. I can't tell if it's just me or, but ok, someone suggested e oh God, everyone's just so on it. So, uh some of these are gonna trick people up but no, well done. Um So yeah, that is the correct answer. Um And I thought it was just quite a useful question because it just makes you think about um all the key um findings that you'd basically find with different causes of vomiting. Um So yes, Lauren, correct. E is the correct answer and actually moving on from that. What, what then do you think is the condition here that we're talking about? Again, this might just be me that I can't see it, loading, got some interception suggestions. Excellent, excellent. So yes, that is correct. Um So I suppose the key things in this history here is that it's the age, age is very important here. Um The blood in the nappy, it's not quite red current described here, but I don't think they'd be that nice to you. Um It's green vomiting and there's a mass in the upper part of the abdomen. So yeah, well done in terms of going through what all the other um findings mean. So, corkscrew appearance would be more in keeping with malrotation with volvulus, the portal venous gas on the abdominal X ray. And pneumatosis, intestinalis as we discussed before is more indicative of the neck. The hypertrophy of the pyloric sphincter is more in keeping with pyloric stenosis. And then I suppose by default, then that leaves us with a target sign. So, yes, well done for those who got that right. Um So this is another very important condition to know about. Um I feel like it's quite a difficult one to visualize er without actually seeing a picture. But it's basically um when a section of the bowel telescopes into the next dis distal section causing obstruction. And um because of the way that the small bowel is basically less wide than the large bowel, it, the most common point for this to happen is that the Ileocecal valve and if untreated, this can lead to quite serious complications there as you can see. And it's most importantly, it happens between the age of sort of 6 to 36 months, although peak incidence probably more like 7 to 9 months and again, boys are more likely to be affected than girls. And these are just some images just to help you visualize. Um what interception actually is, I didn't quite get it until I saw some images there. But yeah, you can see the top image there, it shows you where the valve is and then how you got basically just telescopes in on itself. Um So in terms of what causes it again, no clear cause um sometimes there can be a lead point. Um So things, it basically just predisposes someone to having that weakness in that certain bit of the bowel. I'm not sure. I quite entirely understand all of it, but it's, it's things like Meckel's diverticulum polyps, HSP, lymphoma, it could be post operative, um, or it can also be associated with a preceding viral infection, but in most cases, it's, there's not actually a, a real clear cause, Um, in terms of clinical features. So you might, yes, they're gonna be tired, they're gonna sort of maybe draw up their knees and have these periods of sort of crying that just, you just can't calm them down. Um The pain is gonna come as like sort of intermittent pain. The vomiting then becomes bullous in the later stages and you get the red currant jelly stool, but this is actually quite a late sign, but I'm hoping they would include some of these features in the MC Qs just to, for you to be able to recognize a bit more easily. Um And then in terms of examination findings, um they might describe it as a sausage shaped mass that might be a bit too easy again, but just a general mass in the right upper quadrant area of the abdomen would help you think about the fact that this could be intersection distention, reduced, absent bowel sounds and dehydration. Again, all common things associated with vomiting. Um So yeah, here you can see a nice picture of the ultrasound scan finding. So if you look closely, you can see a kind of target or donut shaped sign there and then the lesser known pseudo kidney sign, I'm not sure I'd really know about that if I hadn't researched these slidess. But the target sign I think is a, quite a common, uh, piece of information. I'll give you in questions. Um, but yeah, there's other investigations you should also do, but I think the ultrasound scan is definitely most important for diagnosis. Um And then in terms of management, um, so similar to pilot stenosis, there's obviously a initial management that you need to do. You just need to resuscitate and if they need fluid resuscitation, give that as required, basically need to make them just stable enough for surgery. Um So yeah, using NG tube to decompress the stomach, make them know by mouth. And then in terms of definitive management, you don't actually need to start with surgery first. Sorry, you can actually just start off with an air or contrast enema in in 80% of cases that should solve the issue. Um But if that, if the air or contrast enema doesn't work, then you'll need surgery to reduce that telescoping or if there's already dead bowel bowel resection, unfortunately. Um, and I think it's important in, yes, in that question actually showed that even though they were probably going to try medical um, management first. Um, it's important to let the sort of pediatric surgeon just aware of the case because it may quickly just turn into a case where they need to um operate surgically. So you always get to involve the surgical colleagues in this sort of scenario. Okie Doke. So moving on, we're nearly there. Final two questions now. So question 12, what did people put for this uh question any answers again? Tess, let me know if it's just me. Any takers? Oh, yes. Ok. Lys again, well done. That is the correct answer. Um, and do you mind telling me why you put the answer? Sorry, sorry for picking on you. Yeah, exactly. DK. But I suppose some of some, some of the other responses are correct as well. But why, why would you go? It, it, it also, it says initial management, which is an important part of the question. Yeah, exactly. Fluid replacement first. But actually in this case as well, she is starting to show signs of, I would say shock in a way her BP is dropping, her heart rate is, you know, going high. She's, uh, drowsy. Um, yeah. So actually regardless of, um, yeah, basically with, with someone who's in shock, you need to give them a bolus first. Um, and that doesn't count as part of the, um, other types of fluids that you're gonna give her. So you're not gonna just, you know, minus this off the rest of the type of fluids. That you're gonna need to give her. Um, so yeah, she's in shock or approaching shock. We need to resuscitate her first with fluids. So you're well done. Um, yeah, so I know you'll know DK a very well at this point but I think it's an important one just to have, um, in the, yeah, just have it at the forefront of your mind and to know the criteria very well. Um, so you have these figures in your mind. So it needs to, it's in the name clues in the name. So diabetic associated with type one diabetes, um ketones. So there needs to be ketones three in a gas or a B or two and above on a dipstick on a urine dipstick. Um there needs to be acidosis. So that's a ph of less than 7.3 and with a bicarb of less than 15 and the blood glucose also needs to be high. So above elephant, in terms of what causes it, if you're interested. This is kind of the science behind it. Um But we yes, the underlying type one diabetes pathology is the autoimmune destruction of the beta islet cells in the pancreas. And that's gonna lead to an absolute insulin deficiency eventually and that leads to a rise in a bunch of different hormones. Um Those uh the blood glucose concentrations rise even further. Um and then that's gonna lead to a rise in the ketones due to the breakdown of the adipose tissues. Um then the combination of hypo hyperglycemia, sorry, and glycosidic causes osmotic diuresis and that, that is gonna lead to the patient becoming um very dehydrated. Um And then they're gonna start vomiting as well. So it's gonna worsen this dehydration and it starts a cycle of just worsening acidosis um until insulin is given basically to correct that hyperglycemia. Uh So common factors leading to DKA. Um, so could be a new type one diabetes diagnosis. And that's how commonly DKA presents as. Um, but it can also be due to non compliance device, failure, changes in insulin requirements at puberty stages, um maybe change their diet. So increase injection ingestion of glucose also can be during periods of illness as well. Um So there's a, there's a theme here with the vomiting. So you're gonna, you're gonna find that the child is lethargic, generally unwell, um, abdominal pain. Um, if they've not already been diagnosed with type one diabetes, they might be showing signs of type one diabetes in the preceding weeks. Um, and yeah, concurrent illness as well. Um And then I suppose some key examination findings. So the custom breathing I think is a very uh classic buzzword there. So you're gonna find that really deep breathing and they're just trying to get rid of the ketones. Um They're gonna be breathing quick in younger Children. You might see the recessions in the ribs. Um You will also maybe see signs of shock, you know, dehydration. Um This is also can definitely come up in an OSK. In fact, I'm thinking of a station where this, you know, just be able to recognize signs of dehydration shock, very, very important, both your wrist and your osk exams. Um and then D yeah, reduced G CS, also worried about signs of cerebral edema. We'll go on to that in a bit when we look at the management guidelines and then yeah, abdominal pain and then sort of pear drops. Uh smell of breath. That's another classic buzzword that's due to the ketones. Um Yeah, and in terms of how we investigate it. So yeah, we can get finger pricker test, urine, dipstick, blood gas, um if you can do blood gas, make sure it's venous to be nice. So we don't, we don't need an ABG necessarily in this case. Um And then obviously an A CG as well, especially as uh we managed as patient. So in terms of um the management, so I took this off the best PED guidelines. Um Sorry if I don't know if things have changed, but I feel like it still is very relevant. I know it says the ad version from 2022 can really find as good a diagram and just general um layout of how to manage diabetes anywhere else. Um But as always follow trust guidelines and whenever you get someone with UK, you will get um a very nice um you know, pro pro performer to fill in. Basically, it will be laid out very nice and neatly for you um both in the pediatric and adult setting as well. So don't worry about remembering all of this, but I think it's important just to have at least the initial management um steps at the forefront of your mind and then you just basically follow the um the protocol basically as you go along, managing them. Um So yeah, as you can see here a we just need to actually diagnose Dier DKA. Um So like we went through before the biochemistry there, the clinical signs, the clinical history, you'll be able to diagnose DKA. And then it's important to know what um how the percent dehydration basically because that's gonna basically let you know how much fluid you're gonna need to prescribe. And um yeah, this will become relevant. So, and that's based on the ph there. So you can see ph 7.1 unless that's severe 10% dehydration, 7.2 moderate 5% dehydration and then mild actually, it says 5% there as well. So that's what beed says. Uh apologies if you might have other information there. But that's basically just basically differentiate between severe and moderate UK and the reason why this is relevant um is so you know how to calculate their deficit fluids. Um But before that though, like in this question here, you need to figure out is this patient shocked. So things like tachycardia, um prolonged cap refill time, poor peripheral pulses and hypotension as well. So all those things are gonna make you think right? This patient is in shock and you should actually give resuscitation fluids at a rate of 10 mils per kilo um until their BP and is restored and they just don't seem shocked anymore. If they're not shocked, you can go straight on to um the initial bolus, which I think some of you were talking about there. So 10 mils per kilo fluid bolus um over 30 minutes and you are actually going to take that out from the deficit fluid calculation. Um So it's gonna count basically as part of that. Um So yes, I think it's basically with this, with this sort of question, I think it's very relevant definitely for your written, but also for your OS um exams. So just have a practice at um trying different scenarios with this. Maybe I think it could come up as like a prescribing station. Um If you go and teach me pediatrics as a really good example on the. Um, so maybe have a look at that. If you type in DK A teach me pediatrics, they've got like a worked example of how to calculate the fluids there, but I'll also talk through it now as well. Um So you can see there the formula there shows you the deficit um fluids and you're basically gonna replace that over, um, a 48 hour period. That's what I know. You may see different figures elsewhere, but I think that's the right figure that I've been following at least so 48 hours period. And then you're also, um, going to calculate their total, er, sorry, their maintenance fluids as well. Um, so also have in the back of your mind that, you know, once we start the fluid replacement, that's obviously what you need to do. Initially, we're then gonna start the insulin at a rate of naught point nt five or naught 0.1 units per kilo per hour, 1 to 2 hours after starting the fluids there. Um So moving on. Um, so once you've started fluid replacing, then you've started the insulin and replacement, you're gonna basically want to keep a close eye on them. It's a very intensive process. You need to, you know, 1 to 2 hourly blood ketones, neuro obs um fluid balance. And you basically just want to see, are we improving things in terms of the acidosis, the ketones and the glucose? And hopefully, after, you know, following the proforma, you should get um the blood glucose going before 14 and at this point, um you want to change your fluids to 5% glucose before you had been using the saline with some potassium as well replacement. Um As you're gonna give some insulin as well, it's going to reduce the potassium. So that's why you want to make sure that you're replacing the potassium, you're having them on the ECG as well as you're using, you know, replacing, um potassium there as well. You want to see if you're um, you know, over correcting as well and that will show in the ECG signs. Um And yeah, and then once you've done, once you've started to go below the 14, you then also don't want to go too low. So you don't want to start going below six. And if that does happen, you then use 10% dextrose. Um But hopefully it should just all resolve. Um And then you'll be able to stop the IV insulin infusion and just go back to their normal regime. Um However, in the background, whilst all of this is happening, they should always have their long acting incident. So I realize it's very long. Um But I would just recommend just having a good look at this. Um and just having it familiar in your head. And I think just at least knowing how to start the protocol is very important and then from then on, you will have it all very nicely laid out in front of you. Um And you'll be able to follow it. So I wouldn't worry about remembering all of this basically. Um Yeah, so in terms of complications, so yeah, we talked uh mentioned it briefly there. But yeah, things like cerebral edema, the hypokalemia as you given the insulin and that can basically draw the um potassium intracellularly. So you want to make sure that you're also replacing the potassium and obviously hypoglycemia is where you can really go the other way around. So just have these in the back of your mind as well when you're um yeah, when you're dealing with DKA. So on to the last question, um question 13. So any takers for um this question, any answers here? Still with me? It's the last one now, I promise. Oh, ok, Lindy, you've gone with a anyone else have any other answers A or D? OK. It's a bit of a mixed picture here. So the reason why I picked this question is cos I think it's very examinable a again for your weight and also for your oss as well. Um I think just having a general idea of UTI S if they're typical atypical or um what investigations do is quite important. Um Yeah, just very easy to test on. So actually it's c and you'll find this, actually, the nice guidelines for this are pretty clear. Actually, it's really good for urine infections in pediatric cases. Um And yeah, I basically just wanted to highlight this topic. Um It also comes under the abdominal pain, but yeah, just also very examinable. Um So, uh if you go and teach me in pediatrics, as you can see where I've got a lot of this information from. Um, they've got some really nice tables there which basically, um, show what kind of investigations you need to do, um, in Children with UTI S and depending on, you know, whether they've, um, you know, had a typical or atypical uti, whether it's recurrent, um, whether it responds to the antibiotics. So you can see in this case, we're a four month old, um, and they responded well to antibiotics. It wasn't an atypical e ti and it wasn't a recurrent one. So that means you're gonna get an ultrasound scan within six weeks. So I know it's really annoying to have to remember all the stuff, but I could just, I could, I could just see them testing on this. Um So just so we go through some important definitions here. So an atypical uti would be any of these features here. I think, I suppose a particular one to remember is the like non e coli organism. But also if they don't respond to treatment within 48 hours and, and then in terms of a recurrent uti, yeah, you can see there are two or more episodes of upper uti, one episode of upper uti and one episode of lower lower uti or three episodes of low uti. So good just to have these in the back of your mind. Um And so it was just a little um expansion on the um different types of imaging. Yeah, so ultrasound scan um very good for renal size and also identifying any abnormalities in the structure there. The, I would look up how, what these different scans look like. I'm really sorry, I just didn't have enough time to put different pictures here. Um, but the DMS A, um, basically helps with detecting renal parenchyma defects and scarring and the MCU, I let me try and pronounce that word there. Um, basically helps us to identify reflux issues. Um, so, yeah, that's a general base of why we do these investigations. But yeah, just have in the back of your mind the um indications for these and the timing of when you do some of these scans. So I think that brings us to the end of our session. Thanks for bearing with us. Um So yeah, these are some very useful sources of information for PS um and also where I personally got a lot of my information from there. Um head smart in particular is very good for sort of brain tumor type um information if you want to know a bit more obviously relevant to what we talked about today as well. And the rest of them are a mixture of websites you probably already know about and also different podcasts as well, which are quite useful. So, um any questions at all as well at this point, feel free to ask any questions. But if not, that is, yeah, that's the end of the session. Um So we'll pop the feedback. I think it's already been sent actually, but we'll pop it in again. So if you can please provide some feedback, that would be super helpful. Um And yeah, feel free to ask any questions at this point. Anything about um the session, anything about exams? Um Yep, personally, uh went to leeds. I don't know if that's helpful for anyone happy to answer specific questions about that or um just general any, any other questions as well. So, but if not, yeah, you're free to go basically and if you want any further information as well, these are our socials. Um But yeah, thanks for coming. Oh Izzy. You said you can't find the feedback for me. Uh Is it just I if you scroll up? I think it's just in the chart for, forgive me if I'm wrong. Um Can everyone else see the feedback form link in the chat? If not, I can, we can actually we can post like a link to it. Oh Chat isn't updating. Mm ok. Let me see you outsource a link for us. I'm not sure I'm looking. Um So that's a valid, valid question because if I go off this for, it just goes a bit glitchy when II don't mind trying as well. I don't think like, I don't know how to get a URL because it's just like if you go into it, I might my, my video might start being a bit weird but I'll try and get 1 g like she said, oh, you've refreshed and you have it now. Perfect. Is He Brick? Ok. Have you seen this? It's, it's all good. Mm. And just a little link here as well just in case I found the link now. Oh, thanks everyone though. Thanks everyone. Should we stop you alive? No, finish then. Ok. How is it?