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Ok, both and there we go. So, hi. Um Welcome to today's session. Thanks for joining. Um So I'm Vicky uh doctor at Eastbourne Hospital. And then we also got um I'm Tess, I'm a doctor at Conquest Hospital. Lovely. And we'll be um doing the second part of our pediatrics um series. So we'll be covering a few more topics that we didn't manage to in the other session. Co P is a very big uh subject I would say. Um Yeah, so I will make a start as there's lots to cover, but this is recorded um And we will be uploading to various platforms as well. So, don't worry, um other people can find this as well if they haven't managed to catch alive. Um So just a quick little summary of what we are of who we are. Sorry. So we're a teaching series um aimed at preparing those for finals, but this is obviously relevant for whatever stage you're at um as well and we'll be doing 10 to 15 minutes of timed Mc Qs at the beginning. We only have nine Mc Qs today actually, but then we also have a quiz bit. So don't worry, there, there will be plenty of questions to do. Um, and actually, to be honest, we are kind of coming to the end of the series. I think we may have one or two more sessions, but this might be, to be honest, one of the, the last ones we do. Um, and just in time, I think for some last exams that are going on at the moment. Um, so in terms of what we're gonna cover today, so we're gonna do a bit of cardiology. So, Tess is gonna talk to us about, you know what to do with differentiating causes of shortness of breath, floppy baby, blue baby and this particular syndrome, I don't want to try and pronounce that. Um And then we've also got some uh dermatology questions for you as well, very useful to go through because they're um quite straightforward when you know what the answer is and yeah, very useful to know for exams. Um And then also like non blanching rash differential. So that's not just, I suppose dermatology things, but uh how other conditions can present with the dermatological presentation as well. Um And then just some developmental milestones and red flags questions as well. So I'll let Tess take away with timing it for the uh the MC Qs. OK. So I think we are gonna do a, a minute of question. Um And we just let you know when to change slides. So if we start with the first one? Ok. Question two. Give me a question to you, Vicky. Sorry, I forgot that you couldn't change his life. Apologies and question three. Question four mm. Question five, please. Question six. Questions seven mm. Question eight and finally question nine. Ok. Ok. Done w test just to let you know. Um I found a way of making the polls. It actually wasn't as difficult as I thought it was gonna be. So we can use a pole in the session. I've got them keyed. So you've got them keyed up, they're up, they're ready to go. So amazing. What do you want to hit the first pole then? Sure. So start polling. Hopefully that's come up for rule. Oh, what's even asking me? Let's see if I can run round. Is everyone else seeing the poll? Oh, yes, I can see we're getting some answers in the chat and it, as in the polls showing up in the chat. Excellent. OK. So we've got about two thirds of people thinking it's, oh, no, it's changing. OK. People are still answering. OK. Looks like the majority of people have gone for C and we've also got some A and some D um, so if we just go to the next slide, OK. So it is c um, and the things in the question, um, that tell you that, um, we're gonna sort of go over this in a second but the, the fact that she's never turned blue makes us think it's an acyanotic condition which is gonna rule out some of our answers we'll go through which ones the rubella is a risk factor for pulmonary stenosis and also some of the other conditions. Um the ejection systolic murmur heard loudest in the pulmonary area does suggest it's a pulmonary stenosis. As does the raised J BP and palpable thrill for the people that one for a um they're pro it is correct. You can get pulmonary stenosis as part of to of follow. But that is usually a cyanotic condition which is why that's less likely in this case. So if we go onto the next slide, just to sort of quickly review the normal heart anatomy to make sense of the rest of the explanations, problems with the construction of the heart can occur due to infection, maternal drug use, genetic problems or sort of the environment in the first days of life. If you look the, the fetal heart has these two connections, it is just quick revision. It's got the doctor's arteriosis and the Foramen ovale that's gonna sort of allow mixing of deoxygenated and oxygenated blood. And at birth, you should have decreased pulmonary vascular resistance which causes a fall in the pressure in the right atrium causing the foramen at valley between the two atria to close and then increased blood oxygenation is gonna cause a drop in your circulating prostaglandins which should cause closure of the ducts, arteriosus. So it might be the, you know, in utero, something's gone wrong or it might be that this process of closing various holes goes wrong. So, if we go on to the next slide, you can broadly um group your congenital heart conditions into acyanotic and cyanotic conditions. Um We're gonna look at the cyanotic uh acyanotic ones first. Um And these are broadly where there's a hole um between the two sides, but the flow is still going um sort of left to right. So things only oxygen, your blood is being pumped into the oxygen system. You're not getting any of the blue blood into the rest of the body or if there's a blockage. Um So overall, your blood is flowing in the right direction. Um but there might be a shunt or an obstruction that's, that's slowing things down. Ok. So, these are acyanotic. Your cyanotic conditions is where deoxygenated blood is making it into the body rather than purely the lungs. Um These are the sort of the more more common in inverted commas. Um examples that are good to learn for finals. Um But they're actually very rare in real life and are managed in very specialist centers over time, the acyanotic left to right shunt. So the holes can become right to left sh because of sort of right sided um hypertrophy. That's when you get Eisenmenger syndrome. So if we go on to the next slide, your main obstructive cardiac lesions um are your coarctation. So, narrowing of the aortic arch, your congenital aortic stenosis and your congenital pulmonary valve stenosis, which is what we had. Um in the question, um these are just sort of pictures so you can see where the different defects are. OK. So if we go on to the next slide, I've just summarized in this scary looking table. Um key things that can be useful in your MC Qs less likely that um you're gonna see a congenital lesion, cardiac lesion in um yours are much more expected to come up as, as MC Qs. Ok. So, coarctation, you've got a sa narrowing of your aortic arch, the severity of that narrowing is going to determine your symptoms and it can often be associated with another symptomatic condition. Um for example, Tetanus syndrome, things, things to see in your MC QS. So when they say sort of, well, to be honest, all these babies are gonna be short of breath and feeling poorly, but the words sort of gray and floppy might make you think of cot or a difference in the BP between the limbs or an underdeveloped limb. Um That's being supplied by the blood vessels distal to the narrowing. You are gonna hear a murmur in many of these cardiac lesions. Can anyone tell me in the chat any different murmurs they'd expect to hear in the conditions on this page? I haven't, I haven't popped them on, on purpose. Um Let me just see if we've got any answer. Yeah. Think about what murmurs you might expect to hear in the chat and I will just carry on talking for a second. So, um, coarctation can be mild enough that you only need surgery, um, in adulthood. Um, but in really severe cases, um, you might have to do surgery sort of very early in childhood and use prostaglandin e to keep the ducts, arteriosis open to supply sort of the rest of the body. Um, your congenital A S and PS are gonna have quite similar symptoms which might also include being asymptomatic, but typically you've got your dizziness, your fainting on exertion, um, in severe cases, heart failure within months of birth. Um, and both of them are gonna have murmurs heard in different places and can be diagnosed with an echo congenital aortic stenosis needs regular monitoring. So, echo ecg exercise testing and is eventually gonna need a, a probably a balloon valve, a low plasty or some other valve replacement for congenital ps. You can actually watch and wait. Um, but again, they're probably gonna need it a balloon valvuloplasty. Ok. Has anyone got any suggestions in the chat for mum as they might expect to hear? Are you gonna make me tell you? So, coarctation is typically a systolic murmur that you hear in the left infraclavicular area and below the left scapula as aortic stenosis, just like adults, you're gonna have an ejection, systolic crescendo, decrescendo murmur that's loudest in the aortic area that radiates to the carotids and pulmonary stenosis we had in the question is ejection, systolic, loudest in the pulmonary area. Ok. Um See I found this table quite useful if we go on to the next slide. So this is now the other acyanotic conditions, the holes in the heart. So you've got your patent ductus arteriosis, your atrial septal deviation, uh Do I mean deviation ad the D defect? Def fact, thank you h your septal defect and your ventricular septal defect. So guys, spilner long day on it. Um So like we said, usually because the left side of the heart is gonna pump much more strongly, even though there's a whole blood is going to go left to right, not right to left and they're going to stay acyanotic. I'm, I'm not gonna read out all the information that's on the slides that that'll be available to you later. Um But basically the PDA um will often spontaneously close, but if it's there beyond a year, probably gonna want to intervene. All these kids are gonna have, you know, difficulty feeding, poor weight gain, maybe a heart failure later in adulthood. When you've got a hole between the two sides of the heart, you're also at risk of um strokes. So, in the same way that A DVT usually would go to the lungs, they can cross over that hole and end up in the brain. So someone with ASD needs anticoagulation. Um And then for ASD, you can watch and wait and if they get symptoms, you do AAA closure um and uh similar for VSD as well. Um Does anyone want to throw out the murmurs they might think they could hear in these conditions if anyone's watching this, like recorded, they, it's, it's a good idea to try and test yourself, write it down and pause the video. So a PDA patent, um doctor's arteriosis would give you a continuous crescendo, crescendo machinery, mama and a difficult to hear. Second heart sound. Your atrioseptal defect gives you a mid systolic crescendo, crescendo murmur that's loudest at the upper left sternal border with a fixed split second heart sound. So you can get a split second heart sound when you're, you're breathing. Um But this one doesn't change, it's there permanently. It's always a split second heart sound. And then in VSD, you've got a pan systolic murmur that's more prominently heard again at the left lower sternal border. In the 3rd and 4th intercostal spaces, you can get different types of atrioseptal defect. So you can get ostium and secundum, which is just a diff there's different parts of your um septum. So that's when the septum sodum doesn't fully close. You can get ostium primum, which is when the septum primum doesn't fully close and that actually causes an atrioventricular septal defect. And then patent for, for aa ovale is not strictly an asd, but it's kind of in the same, same region. So if no one has any questions or someone, someone said machinery murmur for PDA. Absolutely. Right. Um So if we go on to question two, so this is now um a baby that's having episodes of distress and feet turning blue. So people just wanna answer in the poll, they think it, what they think the findings may include. So for our people are going for c So this is now a blue baby. So I think you're at our, our cyanotic side of the spectrum, again, sort of generic symptoms you get when there's a cardiac problem, not feeding, well, short, maybe short of breath. And they, this baby does have a murmur, coughing, ok. So most people are going to see um A couple of people have gone for B as well. So if you go to the next slide, so this is a case of tetralogy of fallow and we're gonna go on to look at the four parts of the tor. Um But in this case, um only the options in th three were correct. Um So there are two other things, but I didn't want to give it away by listing four things that would be obvious with the name to challenge you. Um So here, the, the murmur that's described is very similar to question one. It's pulmonary valve stenosis, but this is a blue baby with nail clubbing history of Down Syndrome. Um So it's a slightly different situation um slightly to challenge your fellow. And VSD is one of the features of that. So if we've gone to the next slide, so the there are four sort of coexisting pathologies into challenge, follow that result in a right to left shunt. OK. So these pictures are both showing the same thing. Um You can have a ventricular septal defect which allows flow between the ventricles. Um But that alone wouldn't be enough to cause um sinois, you also have what's called an overriding aorta. So instead of sort of just getting blood from the left ventricle, um it's sort of sitting directly over the VSD. So it's getting all that mixed blood going into it. Then you've got pulmonary valve stenosis, which is providing resistance um to blood. That's sort of in the right um ventricle, which means that it was more like sort of more happy to flow through the VSD because there's less resistance there than there is going through the pulmonary valve. Um So that's starting to cause shunting the other way. And then because of all this resistance from the pulmonary valve because of um resistance from the left side, your right side of your heart is gonna sort of hypertrophy. Um And then that's gonna be so strong, it can push your deoxygenated blood over to the left side of your heart. Ok. Um The degree of the right to left shunt is actually most affected by the degree of pulmonary stenosis that's present. So that's the single sort of biggest influence on how much there is right to left sh if you go on to the next slide, we'll look at the presentation. Um So you'd hope that it would be picked up very early on an scans or in the NI P exam if they hear a murmur. Um but the child may present a little bit later with signs of heart failure, episodes of cyanosis, you can get clubbing, poor feeding, poor weight gain, this pulmonary stenosis murmur and you can also get T spells, which is sort of what the question was describing. So these are intermittent periods where the shunt suddenly worsens causing, you know, symptoms including cyanosis and the triggers are basically anything that causes pulmonary resistance to increase or systemic resistance to decrease. And that can include physical exertion, crying, even just waking up and that'll be very irritable, short of breath and blue. Ok. The gold standard for diagnosing to try to follow is echo. Um You can also use Doppler flow studies to assess the severity. Um and a chest X ray might show sort of a boot shaped heart because of your right ventricular thickening, but that's not gonna be for diagnosis. Um And then we've pop I popped on some of the risk factors. So there are maternal risk factors and then also some associated syndromes like Down Syndrome um which we had in the question I think the mum in the question also had diabetes. Um And it was over 40. So if we go on to the next slide, just to show you management very briefly. And it can, if we keep the doctor's arteriosis open, we, we're gonna send blood to the pulmonary arteries. So we want a prostaglandin infusion. But ultimately, we're gonna want a total surgical repair which might involve open heart surgery more than once if they have the treatment, um the surgery, then 90% live into adulthood. But without any treatment, the progress is very poor and for t spells. Um if you're sort of faced with one as the new junior doctor, you're gonna wanna increase the systemic vascular resistance. So little babies, you just pop their knees to their chest like in the picture and an older child can squat put oxygen on them, call for help. Um And then, and you might consider some of the, the drugs on the screen. But to be honest, um by this point, you, you should have a senior around. Ok. So if we just pop on to the next slide, the other cyanotic condition that I really wanted to um sort of focus on is TGA transposition of the great arteries where you basically have the aorta and the pulmonary trunk attached to the wrong ventricles. So you have two separate circulations that aren't ever joining. So the deoxygenated blood isn't getting oxygenated in the lungs and you're not getting any. Well, it sorry, the deoxygenated blood is getting oxygenated in the lungs and then just going around in the closed system is never getting to the body, which is fine. Um, when the baby's in utero cos the gas and nutrient exchange is happening in the placenta, but it's immediately life threatening after birth. So the only way they can really survive is if they have a shunt between the two circulations. So a patent ductus arteriosis, an ASD or A VSD, usually we know about it beforehand because of antenatal ultrasound. Um Otherwise they might be born blue or t blue within a few days. Um The shunt will initially help compensate, but within a few weeks, they're gonna get respiratory distress, tachycardia, poor feeding, poor weight gain, again, sweating, et cetera. Um So initially, what we can do is we can make those, those shunts a little bit more permanent. So we can do a balloon septostomy to open up the foramen foramen ovale and create our own atrial septal defect. Um But ultimately, they're gonna need what's called an arterial switch procedure, which is open heart surgery. You put them on cardiopulmonary bypass and you literally just switch the two trunks back and at that time, you'll also correct any kind of ASD or VSD that's present. Ok. If we go on to question three, our last cardiology question. Um So pop the pole up. This is a very good idea using the Polls. Becky I'm glad it was easy. Yeah, it was actually one of the students last week that was showing me uh one of my brilliant. So, yeah, I was like, oh, it's actually not that difficult. Uh You've put in the chat that prove is a way to remember. It's like an acronym for all the defects and to challenge your fellow. Very good. OK. So in terms of question three, we've got mostly sees some A s. So this is a pa a case of patient ducts arteriosus. Um and it's asymptomatic. So I get why people are saying monitoring is fine. Um And we would do that up to the age of one because we hope that it closes spontaneously. And if it's asymptomatic, we don't need to intervene yet, but this baby is now more than a year old, it's unlikely to close on its own. Um So we do need to close it. And if we go on to the next slide, the sort of way to close it is a transcatheter closure. OK. So this is just um from the previous slide, I've just summarized what we did before. So it's asymptomatic monitor until one year then intervene. So why do we need to intervene? Why can't we just leave it if they're not getting symptoms? I alluded to it earlier. It's the, the syndrome that was on a very early slide if we go to the next slide. So it's Eisenmenger Syndrome. So this is I described this earlier where basically a left to right shunt starts flowing the other way and you can get sinuses because of this. And this is because you've had such a long time of extra blood flowing left to right that you've got right sided cardiac hypertrophy and pulmonary hypertension. And when this pulmonary pressure exceeds the systemic BP, the blood is gonna start flowing the other way and you're gonna get cyanosis syncope, shortness of breath during exertion, fatigue, chest pain, palpitations, you can also get sudden death, um and hemoptysis um as late signs. Um and because of their sort of ongoing hypoxia relative hypoxia, they're going to develop secondary polycythemia. And also you've got your right ventricular failure. So we can prevent all of this happening by fixing the underlying structural defect. But if we get a get as far as Eisenmenger Syndrome, the increased pulmonary vascular resistance and the hypertension are actually irreversible. So we've sort of missed the boat, then you can give supportive treatment um which can include sildenafil for pulmonary hypertension and treating polycythemia if they're symptomatic, which involves um phlebotomy to try and lower the hematocrit volume replacement with normal saline and iron replacement if needed. Um They're definitely going to need VT prophylaxis and they might need um it's quite as recommended to give antibiotic prophylaxis to prevent infective endocarditis in severe cases. Um The only real way to fix the issue is a heart lung transplant which carries a very high mortality risk. So if we can prevent ourselves getting there, um, why wouldn't we? Ok. So has anyone got any questions about cardiology or pediatric cardiology before we move on? That's just been a whistle stop tour through the AYO and cyanotic conditions. How to recognize and treat. Ok. And if any questions that anyone comes up with later, please feel free to pop in the chat. Um We'll do our best to answer. So if we move on now to question four and five are my dermatology questions. Yes. Yeah. So five, everyone's gone for c I'm noticing that I might have put sea for most of my questions, put the right answer on and see, I don't think question five is so don't be caught out. Ok? So everyone's agreeing. Um This is um, this child can go back to school once all their blisters have crusted over and a non pro in the chat. What this is what this condition is? You all, you all seem to know the management. So does anyone know, can anyone just write what the condition is? Ok. Um If we go to the next slide, so it's chicken pox, which I think you all secretly knew just no one who was willing to write in the chat. Um We're gonna go over, we're gonna do a little fast paced quiz in a second. Um which I hope people be happy to answer, but this is a quite a common description of your chicken pox and they can go back to school once their blisters have crusted over, if we go to question five and then we will do our quick run through of the other RSS. So if people can answer the poll and then also write what they think. This description is those rashes. OK. Looks like we've got mostly D's a few es. Um So if you go to the next slide, so this is nonbullous impetigo. And although fustic acid is a valid treatment, um you would start with the hydrogen peroxide unless sort of unsuitable for any reason. Um And then if they were systemically unwell or if it was a bit more widespread than just this area, you might step them up to an oral antibiotic like oral flucloxacillin. Um Permethrin is for scabies and the sort of supportive treatment in a is um not in a not super inappropriate, but it's not, it's not really gonna clear the infection, the infection will clear it usually on its own, but we, we like to speed the process up um because it's very infectious. Ok. So if we go to the next slide, so we now have a series of pictures and descriptions and I would love it. If people would throw ideas out into the chat, it's completely fine to get the answers wrong. But if people just say what they think it is and or what kind of treatment they would give um that can make this more engaging for everyone. So, um, Vicky, if you pop up the first rash, so if we look at the pictures and then we think that this has got mouth ulcers and spots and blisters on the palms and soles associated with a low grade fever and malaise. So no one got any suggestions. What that could be. If no one answers, I'm gonna make Vicky answer all the questions hand for. Thank you, Kira. Absolutely. Next slide. So it's a hand foot and mouth disease caused by the Coxsackie virus. A 16. Yeah, absolutely. So Coxsackie, it's very infectious. Um So you do need to keep, keep the kids off school. Um, but you don't really need to give them much management, just supportive sort of fluids, Paracet Ibufen and it's gonna improve within 7 to 10 days. Ok. Next slide. Ok. Um To be fair, we've already had this picture. So if we just go to the next slide, so this was our chicken pox picture. I've just popped uh pictures of, of what it might look on slightly darker skin as well. Um So you've got the different stages of the spots with the blistering and the crusting malaise sore throat. It's caused by the varicella zoster virus spread via droplets. And again, the management is usually just supportive paracetamol, some cooling lotions and you keep them off school until it's all crusted over. It was a beautiful concept. So, if we go to the next slide. This is again, a rash all over the torso, but it looks a little bit different. You've got sort of flat, flat patches or splotches and a couple of days earlier, the child might have had some white spots on the inside of their cheeks. The rash started on the head and behind the ears and this spread down the body to the, include the lower extremities and they have choris symptoms and you haven't got any suggestions what this might be measles. Absolutely. Um Any idea what the white spots are called? Yeah. Got another vote for measles. Yeah, complex spots. Absolutely smashing it guys if we go to the next slide, um just going back to the pictures as well. Um It can, it's red on sort of lighter skin but on darker skin, it can look quite brown or like it's pete eye. So you can mistake it for um sort of meningococci sepsis, et cetera. Um So the white spots are called cop spots like we've said it's caused by an RNA virus called I've committed to this now, Paramyxoviridae Morbi virus. It's very infectious. It's a notifiable disease. They need to stay off school for four days from the onset of the rash and avoid any bees or pregnant women. Um And again, it's gonna resolve on its own usually within 7 to 10 days. Um So you can just give them some paracetamol ibuprofen and keep them hydrated 30%. Um, of people who get measles might develop a complication. Uh, that can include pneumonia, diarrhea, and dehydration. More severe cases, encephalitis, meningitis, hearing or vision loss. And unfortunately, uh, more rare but, um, possible is death. So it is, it's important that's why we vaccinate against it, but it's usually a, a self limiting condition. Um, if we go to the next slide, anyone have any suggestions for this, I wouldn't have known this, I think for my finals, but I have seen a case. The key things to look for here in the M CS are like the dimple in the middle of the spot. The clusters. Yes. Oh, someone knows the rash is very good. Absolutely. Yeah, because if we go to the next slide. So this is molluscum contagiosum. It's caused by mos virus. It's very infectious. It's spread by skin to skin contact, which is why they can start like on one part of the body and then we can spread it to another part of the body. It's important to keep sort of towels and clothing set because you don't wanna spread it around, but you don't have to sort of keep off school. It doesn't make people super sick. Um So we don't usually need any treatment cos it just goes away on its own within 18 months and it's not gonna sort of stop them doing their every day everyday activities, like going to work, doing swimming sports. Um There are treatments available, but they can be a bit painful and can cause some scarring. So that's why we avoid it in Children. If we can, we can usually treat older Children or adults if it's sort of affecting their quality of life, cause it's unsightly or if they're having a weakened immune system. Um and that can be like liquids and gels applied to the skin or minor procedures like cryotherapy. So it's usually more sort of cosmetic or for immunocompromised, it's not, it's not usually worth it in, in Children because of the risk of scarring. Next slide. So we have this in the question. Um One of the questions earlier, um I particularly like the description of them being like cornflakes. Um And these Children usually, well, it can look a bit different if you've got darker skin. What, what did I call this in the question? Um And we did talk about treatment actually. Impetigo, impetigo. Absolutely. So next slide, let me just summarize. So there's two types of impetigo. The more common one is nonbullous impetigo. And the whole sort of vertigo, both, both types is um caused by se either staph staph aureus or group A beta hemolytic strep. It's spread by skin, skin contact and it's highly contagious as all of these have been, I think so far. Um So similar to chicken pox, you keep them off school until their sores are all healed or because you can give antibiotics. Um 48 hours after starting antibiotics, they are ok to go back. The actual first line treatment is topical antiseptic like a hydrogen peroxide cream. Um, but you, you can give a topical antibiotic in instead or in addition, and that just helps reduce the length of the illness and, and reduce the spread. It would, it would improve on its own without treatment as well. And, um, like we said earlier, if they've got a more widespread infection or they're systemically unwell or at risk of complications of other conditions, um We can give an oral antibiotic like flucloxacillin. The other type of impetigo is bullous, impetigo. Does anyone know sort of how that differs? What that means if we go to the next slide? Ok. So this is much less common, um usually affects the trunk more or the sort of inter tr areas. So like sort of armpits and groin. Um and you get these often painful fluid filled blisters that burst after a few days and leave a more sort of pale yellow cross. They don't get that golden color that you typically hear about in the um nonbullous. Um in vertigo, it could this one can also occur on your, your buccal membranes and often has systemic symptoms, fever, diarrhea, MLA S, et cetera. Ok. So, next slide. So I had on my fifth year placement, I had a patient with this condition and I saw a pic, the mother had already sent it in a picture and I literally went on Google and typed in like ring shaped rash cos I didn't know what it was. Um Does anyone have any guesses for what this might be? Ringworm? Absolutely. In hindsight, it was obvious, but I needed to Google that day. Um So if we go on to the next slide, so we've got our red ring. Usually the central clearing um might be silvery as well. Itchy, scaly raised and it's caused by a fungal infection. So, unsurprisingly, we treat it with a topical antifungal or if it's more severe, we can do an oral antifungal. Um It's called tinea corporis, which just means dermatophyte infection. Um of sort of the body ringworm. You've also got tinea capitis, which is scalp, ringworm, tinea unguium, which is nail infection or tinea pedis, which is athlete's foot. So it's just all dermatophyte infections of different areas. If we go on to the next picture, we're getting near the end of the rush as I promise. Um So this is little small red blotches and blisters on, on ch on very young Children and older adults. Um it might be on the soles of their feet, other sort of adults and um not so young Children might have it between their fingers and in sort of other skin folds. It's very itchy and worse at night and can affect the whole family. Um And I can see care has already suggested scabies, which is absolutely right for any bonus points. Can anyone tell me the treatment for scabies? I did mention it earlier. If anyone can remember, Permethrin. Absolutely. Spot on. So if we go to the next slide, so it's caused by these little mites that burrow into your skin, especially the skin folds. Um, it can be spread by skin to skin spread and also sort of, um, from affected like towels and bedding and you, you treat it with permethrin or if it's a, a very young infant, you give them sulfur 6% in petroleum. Very impressed with you. You guys, you've got good knowledge. Um if we go into the next picture, so a a rapidly appearing red rash on both cheeks and that might be followed up by a, a rash on the trunk. A few days later, it can be seen in other ages too where there some most common ones are 6 to 10. Anyone got any suggestions. What they think this is Slap Cheek Syndrome. Absolutely. We go on to the next slide. So Slap Cheek syndrome is caused by parvovirus B 19. It's also called um like fifth disease or erythema infectious. And by the time you have a rash you're actually no longer contagious. So if you're systemically well, you don't have to stay off work or school, um it usually just requires supportive um treatment and hygiene measures and clears up on its own. But if you're immunocompromised or pregnant or if you have a hematological condition that predisposes you to a um anemia, then you're more at risk of complications. The main one is aplastic anemia. So, in those at risk patients, you should confirm the diagnosis with serology and then check your full blood count and reticulocytes. Other um complications include encephalitis, meningitis, uh fetal death. Unfortunately, if a pregnant woman gets it. Um and it more rarely things like hepatitis nephritis, et cetera. If we go on to the next slide, I think there's like three more rashes left. Um So this one is one that was in the news, I think like last year or the year before your sandpaper, rash starts on your torso and spreads out to your arms and your cheeks and your very red mouse that we might call strawberry tongue scarlet fever. Yeah. People are coming in with a great answer. So you usually have a sore throat, fever, headache. It's associated. If we go to the next slide, it associated with tonsillitis. Usually it's caused by group A strep. Um So group A strep is a bacteria. Most of us will have been exposed to it and a lot of us actually carry it without having any problems. But young Children might not have been exposed to it, especially because of COVID. So they can be more symptomatic. The most typical thing you get is strep throat, so sore throat and fever, but some Children are gonna go on with who get the group ARA are gonna go on to develop scarlet fever, which has these symptoms. These Children usually need antibiotic treatment. Um and there are potential complications with this condition. So parents need to be given safety netting information which we're gonna go over on the next slide. Um They need to be kept off school for 24 hours after starting the antibiotics and it is a notifiable disease. Ok. So if we go on to the next slide, these are just a couple of things that we might mention to parents, basically, they're at risk of breathing problems, dehydration, acute rheumatic fever is one complication. So sort of sudden joint pain, more rarely, necrotizing fasciitis. And you can also get post strep glomerulitis a few weeks later. So the 999 things II think they're quite obvious like if a child stops breathing or going blue, call 999. And the other stuff is sort of if they're, you know, not having their normal oral intake, if they're a very young baby with a high temperature, sleepy, irritable drowsy, all this kind of thing, you need uh an urgent same day appointment. Ok. And then if we go to the next slide. So this is a, an erythematous macular rash looks a little bit like the measles one, but it's milder less red, the skin might actually feel a bit bumpy. Um And this one starts on the face spreads to the rest of the body and might be associated with a mild fever, joint pain and lymphadenopathy. Does anyone have any ideas? What it could be? There's another part of the Mmr vaccine perhaps. So, if we get to the next slide, it's um rubella, um unsurprisingly that was caused by the rubella virus, um it's spread by respiratory droplets and actually you, you get symptoms two weeks after you've been exposed, which is a bit unfortunate. Um It's another notifiable disease. You need to stay off school for at least five days and avoid pregnant women. Cos um you're at risk of causing congenital rubella syndrome. If you get it when you're pregnant, that's a triad of deafness, blindness and congenital heart disease. So it could be devastating. That's why pregnant women are offered the vaccine um in sort of nonpregnant people. Other rare complications include a thrombocytopenia and encephalitis, but it's usually self limiting. So you just need to stay away from people for five days. And then I think my last rash is this one. So now we've got again, ring shaped lesions, but they're more target lesions. So they've got a dark center and a ring. This one starts peripherally and spreads centrally. Any ideas what this could be? Ok if we go to the next slide. So this is an erythema multiforme. Oh um We've got a correct answer in the chat and within seconds. So I'll allow that. Um this, this is a hypersensitivity reaction usually caused by an infection. It can be viral or bacterial. Um, in particular, something like HSV or E VV. But it can also be caused for some vaccines and um medicines including NSAIDS, antibiotics and uh statins and antiepileptics. The treatment is usually sort of emollients and then hope that it improves within 2 to 6 weeks. Ok. If we go on to the next slide. So these are some other sort of derm conditions didn't cover eczema and psoriasis. Acne cos I hope everyone's familiar with that by now. Um All those sort of specific peds ones to look at would be the staphylococcal scalded skin syndrome caused by a bacterial um toxins. The differentials for erythema nodosum cos it can be a sign of something serious underlying um and then the other viral exanthem. So red condition. So Duke's disease uh Parvovirus B 19 shouldn't be on that. That's um Sep Juke syndrome and Roseola infantum. Um The picture on the screen is eczema herpeticum. So that's when you get your e uh herpes virus infection of your eczema if you've got breaks in your skin. So that's a uh sort of a condition to look out for. You can also get cellulitis associated with eczema if there's breaks in the skin and, and bugs are getting in. So those are important ones to think about in your exams. OK. I'm gonna hand over to Vicky. Now, who's going to take you through a non blanching rash for a change? Hello. So, yes, over to my section. Uh So we'll start off then with this question here. So if you can cast your minds back to when you first saw this, I'll start the poll. OK? Gotta be a split at the moment. Give it another few seconds. Anyone else wanna give it a shot? Ok. I feel like that's enough time. So, yes, well done to, I think most of those who answer d but I also see where that person who answered C is coming from. Um So yes, the answer in this case is um HSP, I'm just gonna abbreviate to HSP. So let's go through why that is the case. Um So the reason why I actually brought this topic up is cos I think it's important to think about um differentials of a non blanching rash, rash because obviously uh the most um worrying one of out of all of these differential would be something like a meningococcal septicemia. Um And I think, be able to distinguish um you know, what could be causing the rash and especially when it's non blanching um is, yeah, really, really important. So you feel confident in your diagnosis that you're managing the patient safely. Um So hopefully in the stem, he picked up the fact that they're basically systemically. Well, that's what I was trying to get up with. He's been feeling well, but awake and alert observation shows hemodynamically stable. So, um this boy is, yeah. Well, um even though he says he's been feeling unwell. Um And the key bit about the rash is so yes, although it is non blanching and then that, that's a whole load of different differentials there. But I think it's mainly that combined with the fact he's systemically well and the location of the rash. So typically presents HSP T presents on the lower limbs and buttocks. Um If I was being extra nice, I could have given you an image and that probably would have sold it to you a bit more as well. Um And you might get that in the exam as well. Um And then also the joint pain as well. So like an ache in the ankles and knees, very common in um in HSP as well. Other things that you could get, which I didn't put in this question are um you can get the kidney involvement. So his urinalysis does show like it may be starting to affect his kidney slightly with a bit of blood and protein there but not quite in the region of sort of Nephritic syndrome. And you can see as well from his bloods that his urea and creatinine are within range. So no acute kidney injury there. Um So yes, all of this to me points towards HSP in this case. Um However, let's go through the other differentials. So starting from the top sl E so yes, that can present with a vasculitis type rash as well, but typically not in the in the area that is stated in this question. Um And also typically you might have a longer history of general health issues, I think, you know, so suddenly present with a rash and it presented SL E would be quite rare and also the age range as well in this case, um a bit on the young side to be starting developing SL E. Um I just think it's probably unlikely in with the short history here and um and everything else that's going on and then b we kind of covered this. So if they got to the stage where they had, you know, quite visible purpuric rash that's non blanching or, you know, quite all over their body, they're gonna be quite unwell at this point. It's quite a, it's not actually a very early sign of um sepsis. So hopefully, we would have been able to pick up slightly earlier with, you know, the observations going off. So high temperature neck stiffness. Um All those other signs of a meningitis which has turned into maybe a sepsis as well. Um So yeah, that makes it unlikely, see her disease systemically well, and the hemolytic uremic syndrome. So this is quite interesting, it has to revise a little bit to remind myself of what this was. Um So basically, it's a triad of microangiopathic hemolytic uremia, an AK I and thrombocytopenia. So if you just remember that if the platelets are normal, there's probably more likely to be HSP. Because the platelets aren't low platelets aren't feature of the HSP here. Um, in H US. And the option E as well, you're gonna get low platelets. There's also no AK I, in this case, I suppose you could and couldn't get an AK I in, in HSP as well. Cos it, it does affect the kidneys but typically renal function is preserved in HSP. Um And yes, so it's a tricky one. I know it's not, maybe not loads of things to differentiate, but I think maybe just go off the platelets by themselves. And also the, the rash tends maybe not to be as um in a, in the location that is describing this question. And also it's more like PETE K I rather than a puric rash. And I'll go through some pictures to show you the difference between it's mainly the size of P TK or a bit smaller. Um And H US typically occurs after an E coli infection. So actually an, an additional thing that you're gonna get here is probably some bloody diarrhea. Um You can get abdominal pain as well in both C and D. Um But I think it's gonna be more of a, a prominent feature in the H US as well. So it's a tricky question actually looking like dissecting this and then just going down to the last option ITP. Um So this basically happens when um a purpuric rash occurs because of low platelets So a look here, the platelets are normal. Um And um basically that results in a puric rash. It usually um follows a viral infection. Um And you're not really gonna get again, the type of rash that you're getting here and uh in the location and also the other sort of achy joints, again, a tricky one and the low platelets as well. That's another differential approach of fat. So let's go through HSP in a bit more detail. Um So HSP is a type of vasculitis and as soon as you see a purpuric rash affecting the lower limbs and buttocks and you see that systemically well, just have this in the back of your mind as a differential. Um So the reason why you d you develop this rash is because you get sort of iga in complement components deposited in the vessel walls leading to inflammation. And this most commonly happens in Children and especially between the ages of 2 to 11, the actual mechanism behind it is still unclear. Um but there are some risk factors so can proceed a, you know, a viral infection or upper respiratory tract infection. Um sorry, the the the infection would come before it and actually typically happens more commonly in boys in terms of common symptoms and signs that you're gonna see. So the uh the puric rash and that distribution um is a big hint, joint pain is also very, very common. You may get abdominal pain um and signs that it's starting to affect the kidney are things like the um frothy urine. And that would be because there's large amounts of protein in there. Um And this can lead to sort of nephritis. And then eventually, if you're seeing more than two plus protein on the urine dipstick, they may have a degree of nephrotic syndrome and therefore some edema as well, sort of around the eyes. Um And you may also get hematuria again due to the renal involvement. Uh you may also have a sort of low grade, low grade fever as well. Um But generally, they're not going to be that unwell systemically. Um in terms of investigations you can do. So mostly you can actually diagnose this clinically. But obviously, I think any child with this type of rash, you still just want to keep your differentials open. So just double check their vital signs, things like their BP, um urinalysis, basic bloods. Um and then you can send yeah, the urine microscopy for sort of further testing there. Um in cases where the child is getting sort of severe abdominal pain, you're probably gonna wanna think is there anything else going on here? Especially maybe they might start to develop bloody diarrhea as well. So yeah, just um yeah, just react to that and maybe consider imaging like an ultrasound scan. And then um in terms of renal involvement, it usually tends to settle by itself, but you may need to um investigate it further with a biopsy, but you'd, you'd have that under specialist guidance. Um So in terms of management, it's usually gonna spontaneously resolve with supportive care paracetamol may consider steroids in terms of the follow up. Um Children need regular urine dip and BP monitoring for six months after diagnosis. In terms of how frequently that happens, that sort of varies trust by trust. Um But yes, we will be, they typically be monitored for six months um because you can get a relapse of the, of the condition. Um You can also get renal failure. It is rare and you know, nephrotic uh syndrome as well. So yes, just be aware and let's just go through non blanching rash as a whole topic here. So, um in terms of what makes it non blancher. So I mean, if I go to the next slide first, so non blanching means that if you sort of press on it, it doesn't disappear. So like the example here with the, with a clear glass, if you've pressed on that, on the rash still there. Um Yeah, it's non blanching. Um and you can get sort of petite. So like I was saying sort of less than five millimeters diameter purpura just a bit bigger and then, um gosh, I can't pronounce any of these words. The last er, er bit there is more like a bruise. So that's really, really um quite large. Um And then here, you can see on the picture to the right, the difference on the same picture between a Pura and PETE. So other causes of non blanching rashes, which you're gonna rule in and rule out sort of depending um on the associated symptoms. So we've been through a lot of these already. Um So I won't cover the first four, but the last two. So even just sort of forceful coughing can um cause these type of rashes, I probably not as significant as you'd get in some of the top, the further up conditions. Um But um yeah, certainly you could get petite i from, from coughing. Um And then always have in the back of your mind, non accidental injury as well, depending on um the location of it and the pattern of it. Um you know, always seek senior advice in that case if you're not sure and you, you are suspecting a safeguarding case as well. Um So do just have that in the back of your mind. Um And yeah, this is just a little diagram from, from, don't forget the bubbles, definitely an excellent website to seek uh more information from. But yeah, this is just sort of categorizing them again, sort of you get infectious causes, mechanical causes, hematological causes and vascular causes. So just have them in the back of your mind. And then actually, I've got very helpful. Um What do you call it uh guidelines from? I think this is from Barts Hospital. It's one of the a really good guideline. So just always have a back mind. Are they unwell? Do they seem septic if yes, treat as the meningococcal sepsis? Um if they're well, and they have all these key features of HSP, sort of joint pain, abdominal pain and the pupil out on the lower levels of buttocks, you're gonna treat us HSP. Um And if no, you can see this garden has a very low threshold of just treating this as sepsis. Um And then if you don't have the big sort of pupa and it's more like pete sides a size of rash, it takes you through um other things you can think about so I can fit it all on one slide, but I'll move on to the next bit here. Um So yeah, there's other differentials here. So if you're seeing low platelets, um think itp H us other infections, malignancy as well. Um Yeah, so actually key things to remember are, are they unwell? Um what is the distribution of the rash? And is it purpuric if it's pial, do they have a low platelets? And then um it sort of leads you down these different ways of thinking. Um So yeah, if you want to actually get a copy of this er guideline, you can go on, don't forget the bubbles uh non blanching rash and I think they actually have it on there as well. Um Yeah, that's where I got it from, so moving on to question seven. So I'm just gonna pop the slide. Uh Sorry, pop the pole up. There we go. Give it a go and you take us for this question. Hopefully it's a bit more straightforward than the previous question. OK. I'm getting a resounding agreement with the answer to this. So yeah, well done. Um 100% of you got the right answer there. So yes. Um correct. So you didn't fall for the trap of not reading the questions exactly which of the following would you not expect the baby to do yet? Um So exactly that would be option C um And the rest you would all expect um a 10 month old to have done by now. So moving on to this lovely table here. So I think to be honest with developmental milestones, it's really um good one to just know the key development, er sort of milestones because um in the exam, it can be quite a straightforward question, easy marks um because it typically is sort of a right or wrong. Although I think depending on the source that you use, they may vary by like a month or so in terms of like when you're able to make a tower of two bricks or three bricks. Um So I think as long as I think when they give you these sorts of questions, they will, they will be fairly obvious, be a bit mean to sort of have a difference between 12 and 13 months, for example. Um So just have a sort of general idea in your head um of things like I think typically the earlier developmental milestones are a bit easier to differentiate between. Um And yeah, so I was make a table like this, you can screenshot this. I'm pretty sure I just got this off the MR CPC H um websites if you just have some links at the end, so you can type this in and it's available for you to look up. Um And just have an idea of some key ones. Um And I'll run through, I think what's important as well to know is when to sort of worry and what months are the sort of red flag months to be doing things by. And another important point as well is to remember to correct for gestational age. Um So if you got a premature baby, um and they may not, you know, yeah, they may not be achieving things at the same time because you need to learn correct for the gestational age and you typically do that up until two years of age that you'd correct. Um Yes, so yeah, just have a little look at this. And actually, I was listening to a podcast about this just to remind myself about the development of milestones. And I think an interesting way of trying to remember all of these is to like formulate your own story. Um, so the pediatrician in this podcast was saying you can like, liken it to waking up from an alarm clock in the morning. So you like, wake up at six, you start to grimace and then you'd like turn around, reach the, for the alarm clock. So it's quite interesting way of like, thinking about it. I wish I'd probably known about it when I was revising. So maybe thinking a way to make it easier to remember. Cos I know it is a bit overwhelming trying to um look at all this table and, and try and remember it all, but I think it is worth it for the ease of marks and it may come up, I suppose in your OSC as well. Oh, what was the podcast? So it was the um Great Ormond Street podcast. Um And it's the Mr CPC H I don't know if I'm pronouncing that properly. It was basically the pediatric exam podcast. So some of the stuff is higher level, then you'll need to know for your exam. But it's you, I think it's quite a easy listen, to be honest, it's not too difficult to understand. And yeah, the one on developmental milestones is pretty good. So have a listen if you want to know more. Um OK. And then moving on to question eight, I'll pop the poll in the chart. Excellent. Again, this is a fairly straightforward one. So I'm glad that you guys have everyone who answered is getting this right. Exactly. Well done. Um, so yeah, 18 months is correct and that's when you start worrying if they've not started walking by. Um, so this brings up the topic, er, of developmental delay. So, um, yeah, developmental delay is a broad term, defining delay in any of the four developmental areas. So, um, sorry, I didn't actually explain that very well in the previous topic. But yeah, just to go through then. So yeah, we've got gross motor, fine motor can go of speech and language and social. Um, so that's what is meant by that. Um And in terms of you can also get global developmental delay. That doesn't mean deer developmental delay in all of those domains. It can just be in sort of two or more. So you could just have in two areas and that would still be global. Um, oh, duplicated the slide oops and then in terms of differentials. So it's quite a broad question if you say, you know, what could be causing developmental delay, so many different things. And this is the way I think gee I sort of borrowed this off geeky metics. So this is the way they um categorized it. So you can get prenatal, intrinsic, prenatal extrinsic. So intrinsic, I suppose is genetic things, um, that you can't really sort of control. I suppose extrinsic extrinsic would be sort of any, um, yeah, infections or uh terregens such as alcohol um to get perinatal. So during um the birth and then uh postnatal as well. So what happens, you know, after and I think just yeah, have a broad range of differentials in your mind. I think a classic one that they like to ask about is um things that would indicate maybe cerebral palsy, I'll go through that in just a second. Um Yeah, sometimes no cause is found at all and it can be because of fairly benign things. Um such as, you know, maybe if you're growing up in a Multilingual home, uh your language may develop a bit slower because you're actually developing two different languages at the same time. But eventually you will excel and catch up with language development and then other things like neglect as well can affect your development and engagement, especially the social interaction side of things. Um Yeah, so have those as well in the back of your mind. Um In terms of investigations you can do. Um you can do, I suppose initially you they might present in the primary care setting, but then you refer to a pediatrician as it is a really difficult area to, to navigate and you're gonna need other specialists as well. So not just the pediatrician but um you know, audiologist, um physios, etc, all lot lots of people involved in diagnosing these um B yeah, a history examination bloods, um MDT approach and then other investigations like genetic testing and all sorts of other testing, er depending on what your differentials are, which can be quite broad. Um Yeah, and this is just a example of some guide uh hospital guidelines are gonna vary, I suppose depending on the trust. But yeah, just so you're aware this is what uh you may consider. Um And yeah, this is another nice table. Um So yes, I think just to remember key things like um I think walking one is useful to know about um also communication. So yeah, if you're not starting to babble by six months um and other bits and Bobs, yeah, this is basically just a good overall table. And then I've got some more specific ones here. So yeah, with the social side of things, if you're not smiling by 10 weeks, that's a red flag. Um gross motor, if you're not sitting unsupported by 12 months, not walking by 18 months, that's a red flag. Um Fine motor showing hand preference before 12 months and then speech and language not knowing 2 to 6 words by 18 months. And then also regression at any age is a red flag. So if you were able to do something and then suddenly you're not, um then that's also a red flag which would cause concern for a referral. So I think things like showing hand preference before 12 months, that's I suppose an examinable point, we could say that's quite indicative of um cerebral palsy. Um And then I suppose any um issues with social side of things could in indicate autism as well. Um So yeah, II think there are two type of developmental delays that they are, they'd like to examine on another one which is coming up in just a sec. Um is also another examinable topic which could present in developmental delay. So without further ado, let's move on to the last question of the night. So I'm gonna pop the pole in there. Give it a go. I'm fairly sure actually that this is completely based on the question I got in my exam. So I think it's fairly examinable um question I give it another minute or so or few seconds. Anyone else wanna give this question a go? OK. Who getting a bit of a a split here? Um So I think the key word here is initial investigation. So for 62% of you, yes, you are correct. It is a creatinine kinase. And basically, I think all of the answers here are correct in a way as in, in terms of investigations you would do. Um because um in this case, hope we've all picked up on it that the picture over there shows, you know, a gower sign. So this child is really struggling with um getting up onto his feet. Um and this typical pattern of sort of using your arms and then lifting yourself up like that um shows sort of proximal weakness there. Um So, yeah, this is a sign indicative of, er, a muscular dystrophy probably at this age. More of a Duchennes. Um, the history as well here is becoming increasingly clumsy. So I think we're all on the same page that this is a muscular dystrophy, likely Duchennes. Um, so the first test you would do is a creatinine kinase. It's not the only test you would do, but it's, especially if you're in a GP setting as well. This is probably the most appropriate one to, to start off with at least all the rest of them you would do eventually, some, you would probably do earlier than others. Um So yeah, lung function tests and echo those sorts of things may come a bit later on down the line as this might be quite early stages of um Duchennes. Um But yes, definitely genetic analysis as well. But that I think if we think about initial investigations, CK would, would Trump um the rest of the options there and let's go through why CK is important to test. But first, let's just explore muscular dystrophy as a topic. So it's a group of inherited disorders characterized by progressive mus muscle weakness and wasting. So, the two most common are Duchennes and Becker's mu muscular dystrophy. Um And the reason why they affect your muscles are because they, um there are mutations in the genes, er, which are responsible for production of proteins, um which are key to muscle development ie dystrophin and um with, with those mutations, it basically results in progressive muscle degeneration in Duchennes itself. You don't get any dystrophin production whatsoever. So that is why actually it, it's quite a quick progression, I think with, with Duchennes versus Becker. So yes, in terms of what actually causes it. So both er, diseases are examples of excellent recessive conditions. So that is why um yeah, females will not be really affected by it compared to males because females have two copies of the X chromosome, whereas males only have one. Um and it occurs like I said, yeah, mainly a mutation in dystrophin gene. But sometimes it can also and these, these mutations can sometimes be spontaneous, you may not have just got it from your parent. Um And then in terms of presenting features. So yeah, progressive weakness starting approximately then moving more distally. Um and then you might get delayed milestones. That's why it relates to the previous topic. If you see a child who's really struggling with walking side of things and that, you know, maybe they are trying to walk, but their gait is very clumsy and then just have this as in the back of your mind as a differential um in terms of examination. So you're gonna find, like I said, weakness, you may get um sort of calf pseudohypertrophy. So it might appear actually quite big these calves, but it's actually the fattened tissue replacing the muscle tissue, you might get all sort of bottling gait, tiptoe walking Gaer sign like I like shown in that picture. Um And it might affect your reflexes, it might give you flat feet, difficulty, inability to squat. Um So yeah, in terms of diagnosis, like I said, um creatinine kinase would be your first go to and it's more accurate in the earlier on you do it. And that's because so it's an enzyme which leaks out of damaged muscle cells is typically elevated from birth peaks at around the age of two and then it steadily declines due to progressive muscle wasting. So, if I mean, you would hopefully have already diagnosed it by then. But if they are already at the point where they're wheelchair bound, you may not actually get um a very high C A creatinine kinase level to show that they have the genes because by a point, all the creatinine kinase is probably um wasted away other things we do genetic analysis, muscle biopsy. Um And yeah, e examination findings, electromyography, e CG, echo lung function test. Those are important because the heart and the lungs can be affected as well. Um It's gonna be a multidisciplinary team approach. Um So in early young stages, you can steroids can help with managing um you know, maintaining the function of walking for a little bit longer. Um physiotherapy bit D and calcium and other sort of prosthetics, which might help with the with the walking as well. Um however, eventually is it will leave um the wheelchair bound, they'll need to maybe get orthopedics involved cardiology and respiratory surveillance and then ultimately advanced care planning, especially in Duchennes, which happens earlier on and is more severe. So, in terms of prognosis, so, um Duchenne patients usually become wheelchair bound by the age of 12. Um and death can, yeah, can happen fairly early on. Er, Becker is similar but tends to happen later and milder. Um and yeah, less severe than Duchennes. So that brings us to the end of this session. So uh let us know if you have any questions. Um I'll pop the feedback link, so sending the feedback in there. Um So yeah, these are a bunch of resources that we either use during the session to actually make the slides or things that we'd use during our revision. Um Yeah, special highlight to, don't forget the bubbles for the non blanching purpuric rash section. There's a really good page on that and then like I said, the um gosh podcast as well, which is a really good episode on the milestones, but other pediatric topics as well. So hope that was useful. Um Yeah, and remember feedback, please. Thanks for listening. You know, those social media as well. We'll hang around for a little minute or so. Yes, good luck with any upcoming exams. If you have them coming up, you'll smash it. Um Yeah, well done for sticking with the revision sessions. II recognize a few names have been coming frequently. So and good luck, Okie Doke. So if there are no questions at this point, just continue to fill in the feedback form if possible. Um And like I said, yeah, best of luck. And you can always still contact us even though we're, we're not probably not running as many sessions at the moment. Um We will probably be doing some prepare for the F one series as well, maybe a bit early for some of you guys and we may have one or two more revision sessions, but I know exams are wrapping up soon. But, yeah, thanks for coming and attending.