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Hi, everyone. Thanks for joining. Um Can you let me know if you can hear me in the chart? Just so I know that it's working. Hi, guys. Um I'm just not sure if the microphone is working at the moment. Would you be able to let me know if you can hear me? Just so I know that, you know, everyone can actually see discreet and stuff. Ok. Great. Amazing. Thank you. Sorry, I was really confused there for a second. Ok. Hi, everyone. Thanks again um for joining. So this is the first session of the fourth year oy skills, I believe pediatric clinical skills. Um We've got Lauren who's gonna be giving the presentation about this and we'll just give it a few more minutes, maybe two or three minutes just to give anyone else a chance to join if that's ok. Ok. Um I think we'll get started just because they can be quite packed sessions. So Lauren, I'll hand over to you. I think you're on mute. I still can't hear you for some reason. That's strange. Can everyone else hear Lauren or is it just me? Maybe try again, Lauren. I don't know. I maybe, maybe it was just me. No. Interesting. Ok. And do you wanna try and be like leaving and joining again? Sorry guys. Technical difficulties. Mhm. Ok. Well give Lauren a few minutes sorry about that guys. Yeah, there we go. I can hear you. Ok. Ok, sorry about that. All right. Hi guys. My name is Lauren. Um I'm one of the 50 medical students here at Manchester um my base hospital so I'm currently on a GP placement. Um but yeah, let's get right into it. Um Fine. So this is all the part information if anyone wants it, right? Learning objectives today are gonna be the pediatric he history taking. Then we're gonna look at some key presenting complaints and peds with a very, very strong focus on rashes, but I will outline some other pediatric complaints that are worth doing some further reading into, ok, and some developmental history and also how to tackle the video in the AUS station that's often tied to it that comes up most years actually. And then, um as at the end, we'll cover great charts. Ok. So here's what you're taking. So it's the very simple structure of a regular history. I think we just need to remember. There are other things that we need to remember in the history that's very special to peds. So in past medical history, the two key things I was thinking about was definitely birth history and developmental milestones, which we'll come to um Obviously drug history, thinking about known allergies. A lot of kids are also in the process of being diagnosed with allergies. That's also something to inquire about social history who is at home is much more important because we wanna think what's the family dynamic we're gonna be drawing some family trees today. Um Also thinking about social services and ill contacts in the context of um communal disease. Also thinking a bit about family history and we'll also talk about system review and some red flag symptoms. Ok. So there's a lot going on this slide. So first of all, we're just gonna look at the presenting complaint. So presenting complaint can be pain, wheeze, shortness of breath, grunting, coughing, chest pain, grunting is more seen in babies, obviously pain. The parents in very, very small Children will say, I think they're in pain. So from there, we can go, where is the pain that doesn't really apply to anything else? So that's fine onset. When do these symptoms start? Is it acute subacute chronic? And we're also thinking about the sudden or gradual onset. So is it was it happened five minutes ago or has it happened over the last few weeks? So we're thinking about that insidious onset as well. Are they able to describe the symptoms? So with Children, sometimes it can be very difficult to get any information out of them. So obviously, babies and people who can't talk, that's fine. You're asking the parents. And that does provide challenges in terms of, you know, you can't get all the answers because no one can give you it because the patient can't talk. The parent might not know. And that presents itself as difficult if a child is young and able to talk. Um it's best not to ask super leading questions because they might just say yes. Um So for example, if they're like, oh my tummy hurts and you're like, oh, is it a sharp pain? They'll go. Yes. Is it dull pain? Yes. So try and just make sure you're really asking those open questions. So how, what does it feel like? And if they go um I don't know, present the two options, never ask one because they will just say yes, such as something to be to be mindful about um for coughs we're thinking about, is it wet or dry and thinking about blood? Um So hemoptysis as well for a red flag symptom radiation pretty simple um associations uh excuse me, um any other symptoms. So we're thinking about fever, sore throat, headaches, body aches, fatigue. We'll do a assistances review in a minute and we'll also think about um red flag symptoms in terms of meningitis and sepsis in a minute as well. But those are just some you can off ask off the bat because they're super easy to just kind of get through um time course, how the symptoms change over time. Do the symptoms vary over the day, especially thinking about asthma with that kind of morning and night time worsening within the day. It's ok unless it's occupational asthma, which doesn't really apply here. Exacerbation and relief. What makes the symptoms better? What about worse severity ones? A 10? You can make it simpler. Sometimes you can get like images of like the smiley faces online and you can ask the kids to point to which one they're feeling like because it's difficult espe if they can't count and they don't understand the concept of the severity. It's difficult. If they're a baby, you can ask like, is this the worst? If you had to compare, like say for pain, you could ask the parent? Oh If this is like the first episode of pain or like the fifth, how does this be? How does this compare to this episode of pain compared to this one? Now on a scale of 1 to 10? If you put that one, is it 56789 if that makes sense? And then how is it impacting them day to day? Especially for things like asthma cos that will be impacting the kids like getting around or they're breathless. They can't participate in pee anymore at school. So that's important to ask about pee's history. Um In the corner, I've just put a little picture of the red book. Probably not in the ay, but in real life, parents will have this on them. They normally take it to appointments, especially if they're very, very young. You can get a lot of information just out of the red book, it will have things like vaccines and growth development, which are really, really key to see how they've been getting on as a whole. So obviously we're doing the regular medical and surgical history. So that's no, nothing new. But the next things are new. So, prenatal history, this means during the pregnancy. So we're asking about any problems picked up during the pregnancy on any the scans or screening tests. What medications did the mum take during his, um, during her pregnancy? And how was the pregnancy? Cos we, we wanna get a whole picture because they're developing in the womb. So if there were problems or, or things picked up during pregnancy that might impact how you're gonna approach the diagnosis or a differential birth history. How many weeks along was the mum at birth? So this needs to be in weeks and days. So was it 39 plus two? Was it 32 weeks? Was it 42 weeks? So need to know about that. How were they born? Was it vaginal assisted or c section any problems during the deliveries? Ed like shoulder dys dosia or um excessive bleeding, they didn't wake up properly, anything like that or any sort of like resuscitation. And also what was the weight of birth? And then a good question to ask about neonatal history is just, did they spend any time in the NICU in a little incubator? And why did they, was it because they were just premature? Did they have some like jaundice that kept going? Did they have a um did they have sepsis when they were born? So, just things we need to know about. Um are they being bottle fed or breastfed? Um This more came from a pediatrician I met in my fourth year who really pointed this out to me. So cos it's difficult to ask about changes in feeding as that is a often a very common symptom, the parents will come in. They're not eating. Ok. You need to quantify that. So first of all, are they being bottle fed or breast fed? If they're being bottle fed, you're worried about changes to volume and times a day that they're getting hungry. So changes to volume would mean say they gave 10 mL of formula just for as an example. And normally they would drink the 10 up to 10 mils, maybe nine mils, but the parents are coming in and going, they're only drinking three. That is a huge change. And we'd be really worried about that for breastfeeding because we can't measure volume. We're worried about frequency. How many times are they being breastfed? Are they latching on for the same amount of time? Do they kind of do it like for a minute? And then they get really breathless and they're tired and they're vomiting, that's worrying. So bottle fed is frequency breastfed. How many times a day are they? Um feeding a number of wet nappies as well? That will also inform us about has a urine output decrease. Cos we're thinking about dry nappies excessive like a lot and there's no wet nappies, sepsis, child development, we'll be asking about relevant childhood milestones, for example, crawling at 8 to 9 months, we're gonna go through the child milestones. Um, after this, I think, um, but you can ask more generally. Do you have any concerns about their development? Cos the parents are often very, very clued up to what's going on. Um, and they'll be like, oh, you know what, they took a while to crawl and I'm a bit worried and they're not walking properly. They'll be very, very clued up. Parents are great information tools for everything they know their child more than you ever will in that 10 minute consultation, utilize their knowledge in that kind of situation and just are they up to date with their vaccines? If not inquire, why was it because they missed the dose? Was it because they were ill? So they didn't go to their appointment. Um, do the parents have a problem with vaccines? Are they immunocompromised? Can they not have the vaccine for a certain reason? How are they allergic? So just make sure you know which ones they haven't had because that can also be included in your differential if they have, um, signs of infection. Right. Drug history. Nothing new. All the same. Yep. Social history. Some new things to add in a social history who lives at home with the child, relationship status of the parents or carers. What type of accommodation do they live in? What does a child enjoy to do in play? Because this is a good question because, say if they normally like to play with dolls and now they don't really play all day, that's really worrying. That indicates to me this child is very ill. They're not engaging in their regular play. Do they feel happy at home? You can often just ask the child like, do you feel happy at home? And they'd probably say yes, if not thinking about some safeguarding issues, um Are they at school or nursery? Ask about what year they're in? You can also ask, do they have any concerns at school that's kind of going into developmental delay as well? That can also give you an idea of how they're doing socially? Are they happy there? Um Does anyone living or taking care of the child smoke? This includes inside and outside the home doesn't matter. Second hand smoke outside counts. So please, please do make sure you ask about smoking outside as well. How's the family coping with the child being ill? Do they need some support from us or someone else? And these are kind of awkward questions to ask. I do understand that, but it is important. It's like, I don't know if any of you have, um, kind of gotten to your psych block yet, but doing a suicide risk assessment is difficult. It is awkward question to ask. Even though you might not feel like it's appropriate, it always is appropriate to ask. You don't know what's going on in their lives, using them for five minutes. You can't, you can't make the full picture about them in five minutes. So it is important to ask about social services. So you can just be like er social service in, involved in your family. And is there a child protection plan in place for this child if social servers are involved or ever have been involved? OK, Pedia. Uh for the family history, this is a little bit different to everything else is that this includes drawing a family tree. We're gonna have a bit of a practice. Um At this later, I will give everyone the key because that's really horrible. But they might expect you to do this in the exam and on ps walls, they do do this in the clinics. So it is something to bear in mind. This is, this does actually happen. It's not just an ay thing, this happens. So you need to draw a family tree, parents and siblings are pretty much key. You can do grandparents if it's relevant to the history as well or they're more involved. You wanna know if anyone else in the family has experienced symptoms, this is not just limited to acute illness, this is chronic illness. So things like cystic fibrosis, you definitely need to document that and any conditions that run in the family, as I said, cystic fibrosis and just as any family history, you need to ask who's been effective if they've died. What age? Ok. These, this is assistance review. So it's just a bunch of questions. You can do a regular assistance review, but these are more relevant to Children and looking for those. Um You're looking for sepsis and meningitis as always. So you wanna think about changes to visual or hearing, it's difficult in a baby, but it can be like, do you think their hearing of vision has changed in terms of, are they not looking at you? Are they not turning towards the sound anymore? Those sorts of things that indicate the child can't hear you increased work of breathing. We thinking about asthma, um recent cold symptoms just generally unwell feeding queues if not or I asked as I said before about the bottle fed or breastfed fever, rash, weight change. Often you can see that if they had, if that hasn't been documented, it will be in the red book. So you can see what their weight was at the last appointment. And if it's like a new appointment, you can compare, you can document it as well and we'll talk a little bit later about what a significant change in their weight is. And when you should be worried, any change in behavior, are they more irritable? Especially in babies? Um, do they ba babies when they're really, really ill, become very clingy? And they don't like to be away from their mum and they'll be actually really quiet. And that's actually what I would say the most concerning is when they're quiet and clingy for. Yeah. And we're about to talk about meningitis and sepsis. So, but your red flags mainly looking for meningitis, developmental delay and sepsis. So we go the red flags in Children. So I'll kind of split it up cos I do understand Children are 0 to 18. There's a humongous difference between a one year old and a and a, a newborn. It's totally different. Um But online, I found mainly a lot of this from the NHS and sepsis trust. But if we're looking, thinking about meningitis in babies, we're thinking about, are they refusing feeds? Are they irritated? Are they having that high pitched cry and even more worrying? Are they floppy and unresponsive? So I put a lot of diagram in the top to show what a floppy baby is. It's a bit odd but they're just very like kind of placid kind of thing and thinking about a bulging soft spot as well. Um Older Children thinking about fever, vomiting, a numb blanching, rash, the muscle skin headache, very very sleepy and seizures. So more typical adult symptoms um as well with babies, if they're quiet and clingy, that can also indicate that they're unwell as well. But that's more general. Um in terms of signs of sepsis, everyone always should be thinking about sepsis on the sepsis trust. I was actually quite surprised by this, but five people die every hour in the UK of sepsis. So knowing the signs are so vital, When in doubt, you can always consult obviously someone senior, especially in a clinical situation. There's um I can't remember what it's called, but it's like the sepsis, red flags. But for Children, they'll often be plastered over the walls in the pediatric um ward. So don't worry about that too much. Um So if they're under 50, sorry over five thinking about uh very, very fast, fast breathing seizures, muscle pale or they're blue, a non blanching rash, um very lethargic or they're cold as to the touch. Children under five, they're not feeding. Well, they're constantly vomiting. There's no urine in the last 12 hours. That means there's been noticing a wet nappy in the last 12 hours. By the way, if anyone has any questions, please just put them in the chart, I can see them instantly. So we're gonna do a quick test that's gonna be drawing a family tree. Um So using the key at the bottom, we're gonna read this passage and then I want you to draw a family tree with a pen and paper and I'll give you the answer in the next slide. I will give everyone a minute cos it does take a little bit of a while. So Ryan who's a man has not been affected by cystic fibrosis but his two twin siblings, Jane, who's a woman and Harry, who's a man have. Ryan's parents are not affected by cystic fibrosis, but Ryan's maternal grandmother was and died of it when she was 56. The rest of Ryan's grandparents are alive. He believes his mum's sister also has cystic fibrosis. His dad's parents are divorced. Ok. So I'll give you everyone a minute to just do that for themselves in the morning. Sorry, I'm just letting everyone um do their family tree before we move on. Ok? I think that's not time or I'm sorry if it isn't, but we have a lot to get through tonight. So this is what your family tree should look like. Hopefully, or at least the main part is to get parents um the patient itself and the siblings. So um let's work back from Ryan. Our patient, who's the one with the arrow to show this is our patient. He's not affected by it. CF So his square is just white, then he's got two twin siblings. So they're connected on a little branch with the circle and the square. They're blacked out as they're both affected by cystic fibrosis. Ryan's parents are not affected by cystic fibrosis. So they're not colored in thinking about on his maternal side. So his mum's mum was affected by cystic fibrosis, died at 56. That's why there's a cross and then her age with why she died. And then the granddad not affected and then the mum's sister. So Ryan's aunt on his mum's side is there we go. And then just to kind of use up all the um, parts of the key, I'll just put his parent, his dad's parents are divorced just so everyone knows what that cross looks like in reality. If anyone's got any questions about that, please drop it in the chart or any part of the history. Would you need to add whether they were carriers? Um, no, I think you can kind of work it out from this because obviously it's skipped a generation that you can, it's not really re relevant to this. Um, as there's already been people in the family who've been affected. So you would assume everyone's a carrier. Um, um I'm just trying to think if there are any scenarios if that is appropriate. No, I don't think you don't need to draw carriers. Just it's blank. If they haven't been affected, colored, they have been affected. You still need to do family trees regardless of chronic disease. Like it's still just good practice just to draw out who's in the family. So it could just be all white squares and circles with no disease. So just keep that in mind as well. I hope that answers your question. Patricia. I do apologize. If not just let me know. All right. So you're thinking about now specific pediatric presentations specifically today, I'm gonna go through the skin. So these are all the ones that are quite key. The only one I would add to this list is HSP that came up last year in my oy um bit of a shock, but it's fine. So maybe add some more vasculitis courses as well, but they will also be covered in rheumatology. II, remember. OK. So the ones highlighted on the screen are the ones I'm about to go through. Please review the rest in your own time. Um I do appreciate a lot of them will have crossover with the GP and the Dermatology block as well. So you've got lots of opportunities to cover these subjects, but it's always good just to revisit cos it is still quite early into the year. OK. There's a few sensitive slides coming up next. So I just wanted to warn any anybody if they were wanted to look away or you were eating or something. OK. So first of all, we're thinking about infective rashes. First, one very common chicken pox. So thinking about acute fever, itchy red papules, they become these are calls that cover the stomach back and face and then spread out. So hopefully everyone can appreciate the red spots that are becoming more vesicular and they can kinda cover everywhere. Very common, more infected rashes, thinking about hand foot and mouth disease. Super classic, always comes up in past med sore throat fever, they refuse to eat, followed by an onset of the tender blisters developing on the hands feet, um and around the mouth as well. So it's symptoms first and then the rash molluscum contagiosum. This is a viral skin infection that causes localized uh groups of umbilicated so that like have a little dip in the center, pearly shiny epidermal papules. So they're just quite pearly looking. They can pretty much occur anywhere. They can be in one spot and lots of spots, but they usually go in about 18 months. They are contagious. They can be very itchy. I think you can often just give a steroid cream and some lotion and that usually kind of helps that it's basically symptomatic treatment. You can't really do much. So, here's some impetigo. So this is a bacterial skin infection causing pustules with the classic honey colored crushing erosions. It looks like cornflakes stuck to the skin can be very itchy and painful. Um So lots of these pictures are very, I would say more severe pictures of impetigo. A and you'll just see it around the mouth and it will create that really not, it will create a very classic yellow honey gold color. It, you cannot miss this. It's very, very typical. Ok. Now, we're thinking about a widespread rash. One that comes to mind as measles, even though we do vaccinate against this, not everyone can be vaccinated. So we still do see it. This is a um oh, what's it called? The one that you report to the health authority? These are, this is one of the things. So with measles, we'd often see a fever, runny nose, sneezing, coughing, watery eyes and then the measle rash starts just like um hand foot and mouth disease. So the c like spots are like. So in that photo on the left, it's this dot inside the mouth. That's what starts first. Often as well as the flat red spot up to like about a centimeter and they start behind the ears and then they kind of just cover the entire body very quickly. So either there's a, so just a recap, the rash will start after the first symptoms. Either you'll get a spot inside the mouth called the cold. So spot or Children will often get spots behind the ear and that will quickly spread across their body. Ok. Slap cheek syndrome. It's also called fifth disease or eryth erythema infectiosum. It's caused by the para virus B 19. It causes a fever, a headache initially and a rash appears days later with typical, very, very firm red cheeks and they're very hot to touch. Um 2 to 4 days later, they also might develop a pink rash on the limbs and trunk with a lace pattern. So I've included two pictures of the very, very bright red cheeks. Um as it is very infectious, you can see all those siblings all have it. Um And then in the middle picture, it's that lacey rash that you often get afterwards. Ok. So this is uh I'm terrible at pronouncing it, roseola infantum. This is very, very common in toddlers. It's caused by the herpes virus. Um starts with the fever up to five days causing a runny nose, irritability, fatigue. Um And when the fever stops, the rush starts, so it'll be a rose pink or red, red spots that b blanch mainly affecting the trunk. It's not itchy or painful. Ok. So hopefully everyone can appreciate what it would look like like on also lighter skin tones and darker skin tones as well. It's very, very difficult to see when Children have a, a darker skin. Cos obviously, the redness doesn't show up as well. So hopefully, um on the right picture, you can definitely appreciate that. There is a book, I can't remember what it's called. Now, if anyone knows it, please drop it in the chat. It's um it's a brilliant book and it basically is showing what skin conditions look like on darker skin tones because there's not enough representation in textbooks um for it and it does become very, very difficult. If you've only looked at pictures of people who are very pale and white, you have no experience So it does become difficult and things will get Mex mess. Sorry. If anyone does know the book, please drop it in the chat cos it is an excellent book, highly recommend it. But also in addition to that, if you are doing revision and you like to add lots of pictures, make sure you have different skin tones so you can remind yourself the difference as well. So you never forget that. Ok? And then lastly a nappy rash. So it's often called napkin dermatitis. It creates these really horrible red and raw patches around the nappy area. They're often hot to touch. They're painful. They're scaly often with pimples and blisters as you can appreciate in all three of these images. They're really, really nasty, horrible. Some of them are actually quite mild derm net have tons of like nappy rashes and they're just all horrible. It's often just supportive treatment. It's just because they're having allergic reaction to the nappies and hopefully it goes over time. Mind the gap. Mind the gap of skin for all. Yeah. Thanks guys. Yep. That's what it is. Ok. So mind the gap for future skin. Oh, what would you got? Sorry, use mind the gap just to create um your learning resources more varied. So we don't always just look at on pale skin. Yeah. So these are just some more specific pediatric presentations that I thought were quite important to include. Unfortunately, we don't have time to go through um any of these. So I do urge everyone please to recap these, especially, especially sorry bronchiolitis. That is like the only thing people come to the hospital is I spent last year's Christmas of ps ward in Oldham and it was just Bronch. There was one kid there with an asthma exacerbation. The rest bronch. It, they all joke about it. It is real. Please review Bron. It's very, very important. It's very much supportive management. But at a certain age, we can start treating it. So it's important to know but the rest might come up in Oy as well. So it's good to know. OK, so just as a quick test, um you can put in the chat, you can think to yourself doesn't matter. But based on this picture, what virus is causing this presentation. Yeah. So you're absolutely right. It is b it is the porus B 19. Great. And a second question. What is causing this presentation again? You can think to yourself. Put it in the chart. Yeah. Yeah. Amazing. It is. E thank you for putting that chat guys. Hump foot and mouth disease. Super classic. Yeah, thanks guys. OK. Moving on to developmental history. Again. Any questions about what we've just talked about? Please put them in the chart. Any questions about this? Right? In the chat. Fabulous Gross Motor Skills. The first one in the, in the Aussie handbook. Not ask Osie handbook, the Manchester Osk handbook. Sorry for anyone who's not in Manchester. I've splitt this up into how Manchester split it up and what they've given as the m as the milestones. If you use other websites like passed or geeky medics or other textbooks, please. How we can we get these slides? Um, oh, I don't know if we can give it to you as slides. Um hm. Can, so one of the team let me know if we can send the slides to everyone afterwards. Yeah. So if you fill out the feedback forms, which there'll be a link at the end of the slides and I'll send the link into the chat as well. If you fill out that feedback form, then you'll get the slide sent to you. Amazing. Thank you so much. Um ok. So going back to the milestones are based on what Manchester said, different sources will say different things. So please do appreciate that if you're looking at other resources and it doesn't add up. This is just what Manchester has said for the oy. So this is all the Manchester students Bible, please just abide by this. Do not look at other resources. This is all you need to know cos there's so many milestones, so, so many. Ok. So for Gross Motor, which is the first category on the Manchester's um booklet. Um So three months they can support their head. Um six months, they can lift their head and also sit unsupported specifically, they can sit up straight without support. So they're not curling over, like, hunched over. That's the first thing they do. They do and then they'll eventually sit up straight with no support. Nine months we're crawling. A lot of the pediatricians will talk about butt shuffling. There's a really good bluey episode about it. Just so unrelated. Um, but butt shuffling can often happen before crawling and it's often genetic. I remember one of the PS consultants at Salford talks about how she was a but Shuffler when she was younger and both their kids were, but Shuffler when they were younger. But, but shuffling think about it as like that stepping stone before crawling. It's not on the ay handbook, but I just thought it was, um, good to mention because, you know, we have to go out to the Real World and it's not all just on the handbook. Ok. So 12 months they're cruising, which means they can kind of walk and guide themselves between objects and they can pull themselves to a stand. So they might be like using the sofa as like a guide to walk against. It will be very, very unsteady walk by the way. So 50 months old, we're looking at a very good walk, so more steady, less wide gait, more together, more of a normal walk. Two years, we're looking at jumping with both feet and also kicking a ball and three years old, they're able to go up and down the stairs one step at a time and they're also able to hop in five years, they're able to skip. There's no four years on this one as well. Ok. So gross motor important delays. So nine months, they're not on, they're not able to sit with a straight back without support. So that's like a that these are hard and fast. Like if they haven't hit it by this day or this, this time, we need to refer them for further investigation and 18 months unable to walk. So those are your two main delays that we need to think about. So, no, we also correct for premature babies. So if a child's born at three months premature, we want them to ex we want them to set at nine months and not six months and walk at 18 months. Is that right? No, sorry. That's not right. Um So for any milestone for a premature child, we're adding on those extra months. So yeah, so nine months instead of six months, please, I'm sorry, sorry. So three months premature, we're adding those three months on because they need those extra three months to develop. I hope that makes sense. I do apologize about that fine motor and vision. So from birth, we want them to fix and follow which means they might look at their parent or caregiver and they can follow them with their eyes and that should be absolutely from birth. Three months reaches to grasp and they can also hold a rattle. Six months, they're transferring objects and they've also got a very, very primitive palm grasp which you can see in the image. Nine months, they got an immature pincer grip, which means they kind of do this instead of this. And they can also bang two cubes together. 12 months. We're looking at that neat pincer grip. So more like this, more the curved fingers immature very flat. 15 months, the two and fro scribble two years, a circular scribble. Three years, a tower of 9 to 10 bricks, they can also cut with scissors and they can copy a circle four years, they can copy a square or a cross and there's will also be a 10 block tower and five years they're able to draw a person. Ok. So fine moments for vision, six weeks that unable to fix and follow that is hard and fast. 12 months, no mature pins grim again, we're adding on premature months. So if the baby was a month or two months premature, the mature pins grip. We're looking at 13 to 14 months, hearing speech and language. So six weeks, they will quieten into voice and vocalize, which just means I'll just make sounds. Three months, they will turn towards sound. That can often be a sign that they might have some hearing problems. But obviously there is a newborn hearing screening test. Um six months bubbles turns to voice specifically. So they're not just turning to like a door closing or a slam. They will just turn to voice or more specifically to voice. Uh nine months thinking about double syllable babble. Uh 12 months, we're thinking about the first words. So 1 to 2 words and they might imitate. So like, you know, when parents go, oh, can you say dadda or mamma? That's at 12 months. At 18 months, they can point to their body parts. They may be able to say up to 12 words. So you can ask them, where's your nose? And they'll be like, oh, it's here. Um Two years, they're joining 2 to 3 words together when they're speaking and they can also say up to 50 words, three years, we're thinking about basic sentences. So I me you, I go to the park maybe less complex. Four years, stories past tense and they can count to 20 then by five years they should know the colors they, how old they are and where they live. Ok. There are no, oh, sorry. Just to mention Manchester said there are no delays for hearing and speech and language. So please say that grain of salt. But again, those are important big milestones if like they're two and they can only say 12 words or they can only say six words. That would be a serious delay and they still need referral. So just because Manchester haven't put them in like this needs to be done at this time. If they're not meeting their milestones consistently, they are developmentally delayed. I just want to distinguish that as well. I'm just highlighting very, very key ones like crawling and walking and then the last one is social and emotional behavior. So at six weeks, we expect them to smile at three months, they'll have, they'll laugh and they'll also have hand regard and by that, they'll just mean, they're putting their hand in their mouth all the time. Six months, uh stranger awareness. So they might kind of like be a bit frightened by people. They might cry, things like that. They're also doing finger feeding. So taking things from plates and putting it in their mouth might be edible, might not be, they might try and reach for toys as well. They can wave bye bye. They can do Peekaboo and they can show their wants. So Peekaboo, they don't have object permanence. So it's really fun for them. 12 months. Understanding of no, they wanna give up a toy and they have object permanence finally. So yeah, 18 months, they can drink from a cup, they can ask for food and drink and they can have symbolic play, which is very, very key in terms of like developmental delay. If they're not having symbolic play. At 18 months, a lot of people might get start to get concerned. Um 22 years, they might have problems sharing, they will be able to feed themselves with a spoon. They'll be toilet tr oh, sorry. By three years they should be toilet trained during the day. Not so much at night often. It can go up to five years for nighttime toilet training. They might, they may need help dressing and undressing. They can take turns with toys. They're able to eat with a fork and a spoon. By four years we're thinking about, they can dress as themselves without help and they're able to do parallel play. Five years. Um They're able to name a friend and comfort in distress. So some really key milestones, you can see how quickly they develop just in a year. Ok. So for social and emotional behavior um six weeks, no social m smiling huge problem. 2.5 years, no symbolic play. These kids need referral instantly. Ok. So to oh God, sorry. So to tackle the Osk Station. Um a part of delay, they will show you a video of a child. What is symbolic play? It's usually like imaginative play. They might be recreating events. So oh God. So they might be like recreating an event like oh they went to a party and they'll make a party with their dolls and they'll recreate it or they're doing imaginative play things like that or they might be trying to imitate what other people don't do. I think all of those come into symbolic play. I hope that answers your question. Ok, so how's to tackle the Os Station? You will walk in there will be someone there. That's all right. No problem. So you'll walk in, there will be an ipad and an examiner and a pair of headphones attached to the ipad. As soon as the AUS station starts, put on the headphones and watch the video. Next to the ipad will be a hot like a blank piece of paper. When you're watching the video, it will be a video of a child doing stuff like playing, talking, walking about, write down every single thing you can think of. They can say words, they can say their name, they know their body part, they know who they are, they can walk, they're able to feed themselves, they're able to drink from a cup, they're laughing, they're interacting, write every single thing you can think of that they're doing whilst you're doing it that will get you marks. The other half of the marks is when that video ends, the examiner will ask you some questions. So the I got this last year actually, and the two questions I got were, what are the four domains of developmental assessment? So you're thinking about gross motor, social and emotional intelligence, fine mo fine movement and I can't remember the other one's speech and moving on to the next question would be is this child in the video developed appropriately for their age? So last year for the one I did, the kid was developmentally like he was appropriately developed. So there was no concerns. It is easy to think. Well, they're showing me this child something must be wrong because like why would they take a video? But they will catch you out by just showing you normal stuff, not only for this, but for literally everything else as you probably all know by now. So just keep that in mind um when you're doing it. So don't be stressed out thinking, oh it's annoy. They'll want me to do, identify what's wrong. They might also just want you to say this is normal. So two key parts to it is watching the video and taking as many notes as physically possible. And the second um bit will just be answering some questions at the end which I think the key thing is identifying if they're um developmentally delayed or not. Ok. In an akie, I struggled to how to manage or handle a baby doll. As in reality, we would have their parents hold them while we measure their head circumference. How do we do that if this is in an aus? I don't know how to hold a doll while measuring head. Um I is it, I'm pretty sure you're talking about the newborn baby exam. We're not covering that today. I do apologize. Um ok. In the exam, if you've ever seen a a newborn baby exam, it's them on the bed. You don't need to hold the baby, the parent doesn't need to hold the baby but what you can do if they're, if they're sitting still enough or if you're just doing it on a doll, so it'll be completely still. What you do, lay them down flat on the bed. So they're here and just have them look up at you and just feed the tape measure under the head and just come around like that and that's all you really need to do. I'm just so sorry you don't need to handle the baby doll. Don't be worried about that. Um They just need to be flat on the bed. The only time you really lift them is when you do the, the startle reflex and that's very simple. You're basically just dropping them into another hand or you just quickly have them on your arm like this and you're just going like this. So there's not, you're not really handling it as per se. Has that answered your question? Ok. Amazing. So just lay them on the benefits and the newborn exam, they don't really need to be up. The only time you need to pick them up is if you're inspecting them back as well, but you can either do that if they're on mum's lap, if they're like kind of sat up or you can kind of just turn them over and hold them basically just kind of like this and have their head just kind of like in your, in your grasp, but they're not like flopping over. But Yeah. Um, Manchester don't teach the newborn baby exam and I hate that about it. It's very irritating because it's such a difficult exam to perform if you've never handled babies before. Um, do ask whoever your supervisor is if you can have some, one on one time going over the exam. We did that last year and it did help, but the amount of times we had to ask and beg for, um, exam practice was irritating. So I do appreciate that. Um But do try and get some time with the consultant to do that. Sorry, I need to move on. So that's it. If anyone's got any questions about how we do the osculation for developmental delay or the newborn exam, I'm more than happy to answer them. Ok. So very quick test. When should a child be walking at the very latest? Is it nine months, 12 months, 15 months, 18 months or 20 months, I'll give everyone just a second to think about it cause I'm realize we run out of time. Ok. Ok. So it's 18 months no later than that. That's what they should be walking. Yeah. Thank you, Joseph. That was great. Yeah, thanks for Oh yeah. Thanks guys for answering. Um A 60 month old child is drinking from a cup on their own. Sorry. Is this child developmentally delayed? Yes or no. Mhm. Yup. Yes. This child is actually not delayed. Thanks guys for putting all the answers in the chat. So this child's actually not delayed. They're actually in front of the milestone. So they're actually expected to drink from a cup at 18 months. I do appreciate. That was probably a very difficult question. Ok, let's talk about growth charts very fast. So we need growth charts because we need to compare the child's size with other Children of the same age and maturity. So we're checking that they're growing properly and we also wanna check that they're growing normally over time. Can everyone still hear and see me? Yeah, thanks guys. Ok. So I know it's a bit pixelated, but this is what a growth chart should look like. So this is between 0 to 4 years old. They're all from the, like, er, the World Health Organization. They're really standard. There won't be any difference between hospitals or services. Um. Oh, ok. That's all right. Um, so they're on the NHS website. They're on geeky medics. They're on the who website as well. So you can find these everywhere. Ok. So it's pink for girl blue for boy. So just to zoom in a little bit more, this is what it would look like if you were measuring head circumference, it's pretty much the same if it's head white. It, sorry, head circumference, weight, length or height. I think that's what you measure. So you can see across the top, there'll be age, the ones in the circles is the months when we get to our older Children, it will become years. Um, actually sometimes I think it's a month. Hold on. Yeah. So, in so when they're under one, it'll be months in the circle and then when they're over one, it'll be years and at the top it's just weeks. Um, along the, the right and the left side is the head circumference in centimeters. And on the lines, you can see the numbers about what centile they're in. So the 99.6 is a centile line. 98 is a centile line. There's no difference between the, the dotted and the straight line. It's just to distinguish between the lines. So you're not just like your brain's not overwhelmed. Um Yeah, it's pretty much the same for all of them. They don't really look much different. It's the curve and then the measurements on either side with the, with the age being on the top or the bottom depending on what you're doing. It's best to use a ruler when you're doing these, by the way because it can get really confusing trying to find all my lines. So when we plot, if they're between the age and 0 to 4, also compensate for prematurity hit. Yes, I will get to about prematurely prematurity. Don't worry. But thank you for bringing that up. That is definitely important in this as well. So when we're plotting, if they're so here, if they're born at term, which means over or equal to 37 weeks. A small dot should be drawn on the vertical line according to the age that it crosses. So age is vertical and then the horizontal is the measurement that we need. So it should just one dot where we need never ever connect the dots do not do that. It's just dots. Don't do anything else. If they're 2 to 18, it's the same applied. But we only measure height and weight, babies. We measure height length, weight and head circumference length is just because they're like they can't stand. So I hope that makes sense. So a baby is born at 48 weeks ago. A baby is born 40 0 sorry. A baby is born 48 weeks ago at term with a head circumference of 45.5 centimeters. All I want you to do is put your finger on the screen now about where you think the dot should go. So using. So we're looking at 48 weeks across that top line and then on the side or the other side, depending on where you think it should be plot where the 45.5 centimeters is. So just everyone have their finger on the screen. I'll give you one second. We're ignoring centile lines for now. We're just, we're just focusing on plotting a value. So hopefully all of you have your finger on the screen. If you don't, this is where it should be. Um I'm not sure if the same thing happened again. Maybe try muting and unmute yourself cos we can see you but it's just not playing the sound now. Yeah, maybe, maybe try to leave and come again. Like last time. Hi guys. Can you hear me? Yeah, that's good. Ok, sorry guys. Ok. So let's really quickly go over that. I'm really sorry that we're going so far over. So with preterm infants that are below 32 weeks, they use a completely different chart. You don't need to, um, do the bottom stuff on that. You don't need to worry about that. I would be super surprised if that ever came up in the ACY, that would be very nasty. Um, but if anyone's interested, you can look this up as well. It's the N ICM chart. Um, we usually use it up from the before 32 weeks to 42 weeks, which would be term. They'd be zero years old equivalent. Um, and then we use a chart from two weeks to six months and then six months to two years. So they get full different charts. Don't worry about it if you were born between 32 weeks and under 37 weeks, this is when we correct on a regular chart. So what we need to do is just do the gestational correction, which means we will plot what the actual value is at their age. So no matter, no matter what it is, say they're 10 weeks today do the 10 weeks and then the actual value plot that first, then we need to calculate the child's actual age minus the number of weeks. The infant was preterm. So say this child was five weeks preterm and they're 10 weeks today means you 10 minus five. So now because that means they're five weeks old in this new age. What we need to do is draw a dotted arrow across it backwards to where the te the five week liners. So just a recap dot On that 10 week line, they were five weeks premature. Draw a dotted line to the five weeks because we've minus 1010, 10 minus five. So now they're five. So we're going backwards across the same horizontal axis. Um And we only do this until they're actually the age of one. So we don't need to gestationally correct after the age of one. If they're born between 32 weeks and 37 weeks, it's a little bit complicated. I do understand that, but we will get through this and we'll go over it again. So this is the same thing. I want you guys to put your finger on where basically the dot And the arrow would go on the screen. So this is for a six months old baby that was born. I've just realized I've used that. Oh, no, I haven't. Sorry. This is a six month old baby that was born at 35 weeks and they have a head circumference of 42 centimeters. So I just want you to put your fingers on the screen. When we, by the way, when we're talking about prematurity, we're saying prematurity from 37 weeks. So if they're born at 35 weeks, they're two weeks premature. Therefore we minus two weeks. Sorry. Just, I didn't write that on. I do apologize. So, prematurity from 37 weeks. So just put your finger on the first value and then the new value of the calculation for the gestational correction and I'm just gonna keep going. Cos I'm very mindful. It's eight o'clock. Ok. So this is what it should look like. So obviously we're looking at the sixth week line. Oh my God. No, I'm so sorry. 40 weeks. Sorry. How long it, so we're minus from 40 weeks cos that is term. So if they're 32 weeks, it's we're actually thinking about six week. No. Sorry. Let me just go back for a second. I'm very confused. I've confused myself now. Right. I don't know how calculated this. Um fine. I've taken four weeks off. Maybe it is from 37 weeks. Oh, I do apologize. I'm sorry. Sorry guys. Um I'm taking four weeks off because they're four weeks premature because we're going from 37 weeks. I think that's actually wrong. Please. To ignore that guys. I ok. I do apologize. Sorry. Oh, no, sorry, I have done it correctly. It is 37 weeks because I've taken five weeks off here. Yeah, five weeks. Prem. Yeah, thank you. Thank you, Paul. Sorry, I don't know why. That just made my brain go weird. Right. I've taken five weeks off. So we'd taken, they're at 42 centimeters we can see along the horizontal axis, which is where the dot goes. And then we've drawn those dot dotted lines five weeks because they're 32 weeks, which means they were five weeks premature. So we're doing that dotted line across to the 21 week line. That's cool. Ok. I do apologize guys for getting confused. I hope it makes sense. There's lots of examples online. Hum. Medics is really great for this as well. Ok. So how do we look at centiles on the chart? So these are just kind of like terminology to kind of understand what the centiles mean if a po so with the one on the photo, if the point is within one quarter of the space from the line above or below, they are on that centile. So in the image there, they're on the 91st centile despite being one quarter above and one quarter below. If they are not within one quarter of either line, they are actually between two centiles. So we can just describe this as being they are between the 75th and the 91st centile. It never has to be just one um three and four on the photo displayed that the centile space can be midway above or below the line or the distance between two center lines. That's just what people mean when they say a center space. So it's either between two lines or like halfway above if the line goes in the, in the middle and the number five is just again showing that um gestational age correction of what that looks like on the on the job. So what do sent outs actually mean a centile line is just the number of Children expected to be below the line. So the centile. So if the child was in the 50th centile for child for for their height, sorry, we would expect 50 of them to be taller than that child and 50% shorter. So when we talk about the naught 0.4 centile and the 99.6 centile, those are the 99 out of 100 Children. So there's two Children, one child that will be this half outlier just because how the distribution is. Um So if we're talking about those centiles, we are talking about the 1% basically 50 out of the 100 Children. If we put 100 Children in the centile should be between the 25th and the 75 centile lines. Ok. How do centiles tie development in babies? So babies don't grow at the same speed. Um They won't grow along the same weight line and they will never ever follow a centile perfectly. They often float around one centile space, so about two in the middle, but they won't follow it to an exact science. So when we would get concerned is when there's a sustained drop through two or more centiles that needs investigation, that's through any time as well. So it could be a week, multiple weeks, multiple months, any sort of time. If there's that drop over two centiles or more, that is concerning for height and length, it's very normal, quite stable. We'll talk a little bit about mid parental height as well. Oh God, I'm so sorry, I'm running out of time um for head some conference after six weeks below the second s centile is abnormal, flat out needs investigation doesn't matter, they need investigation below second centile. Um If the head circumference is above the 99.6 centile, which is the top centile unless they're having certain symptoms. W we're thinking about hydrocephalus so that vomiting bulging poin now they're looking downwards also may be worried about. Um but yeah, Hydrocephalus main thing um because their head would be becoming bigger. So that is definitely worrying but not as worrying as being below the second centile. Ok. So for people aged 2 to 18 again, no one's gonna follow a centile perfectly. But these are the things we should be worried about the height weight or BM I is below the naught 0.4 centile. Thinking about malnourishment. 100% height is more than three ti centile spaces below mid parental center. We'll get that to a minute, a drop of height of more than two cent spaces. They won't be getting shorter, but they will just stop growing. That's what that means. Um And any other concerns in child's growth that ties back to a history. The parent goes, I don't think they're developing properly. I don't think they're getting any taller. Why they stop growing? Those are red flags right? Mid parental centile. This is super easy calculated, average height um based on our parent height. So we need the height of the mum and the dad. Um and then we mark it on the mums side and the father's side, it's in centimeters and feet as well. And then we just draw a line between them and then wherever that line crosses the midsection, which is the centile line is what centile that child should be in. Ok. How do we use it? We compare the mid parental center centile to the child's current height. So is that child between the 75th and the 50th centile now or what we want them to be based on the parental centile? If there's a large difference, which means it's more than two centiles. So if this child was in the ninth centile, we would be worried that is not normal. Ok. So it's likely a growth disorder. If it's something like that, that's how we use it. Um Quick test. Um I do appreciate running out of time. So I'm literally gonna go through this. What centiles this child growing along for their weight. You can just think about this. Don't need type it. If you said 25th centile, you are right. This infant is born at 28 weeks gestation. Very, very small child. Ok. Would we be concerned about this child's weight? Just a yes or no. I think it's quite easy. Yes. There's a failure to thrive as this child's weight has started between the 25th and the 50th centile and is now at the second centile and this occurred over a year. So you can see they've dropped two centiles over time. As I said, it doesn't matter how long it is, they've dropped two centiles. This is worrying. Ok. Any last minute questions, I'm so sorry. I run over and please please please do the feedback form. If anyone, I will drop it in the chat now. Hopefully that works. Yep, that does um you will get the slides if you fail to feel that form, but also that really helps us out. I'm so sorry for running over guys. Yeah. Any last minute questions, I'm more than happy to answer. Amazing. Ok, I feel like if there's any questions, feel free to email us on the Co blue, we um email as well and we can forward that to Lauren. Um Thanks Lauren. That was really, really good session. Um We'll now move on to the Aus practice part of this, of this session. So if you are staying for that, please feel free to stay. But if you don't want to, you're good to leave. Um, it's up to you, I'll give you a few minutes just to leave if you do want to. Ok. Um Right. So it seems like we have quite a few people here for Os practice are slowly decreasing. I think we've got three facilitators today. So we've got Renee Gender and Denise. We've also got two doctors, Leia and Shala who are also gonna help out with the osteopro. Um Could you guys just give me a shout if you are here as in the facilitators like Renee and Kendra. Ok. I think we actually only have the two doctors at the moment. Um Let me just see if I can find where the other other facilitators are. Ok. Um I think we've got most people. So we have three breakout rooms. Um And what I'm gonna do is we've got quite a few students. Actually, I think there's gonna be around 10 in each room. So if you can all click on the breakout sessions, tab on your left hand side of the screen, I'll tell you which one to join. I'm just gonna do it. I'm gonna tell you which one, then you just click on it and join it. So, Ashg Ahmed Ahmed, Asma Banu, Bianca Charlotte, Dina Gita and Gift. If you guys want to join the first ones that's Denise's session. And then Janella Jesselyn Joseph, Jude Krisha Laith, Lean Leia. Oh, wait, le doctor, sorry, Lean and Leja, if you want to join the second one. So that's GREs. And then Mata Mara Raha Rem Sadat Si Yunis and Zain, if you guys want to join the third one, which is Rims, um go ahead and do that. If anyone's not sure where they are, just stay here and we can sort that out as well. Um Does everyone know which room they're going to? Can you guys let me know if you like in the chat, if you aren't sure which group you're in or if there's another issue going on, just let me know and she and le you guys are free to join any of the breakout rooms and um you know, go between them to help out if that, if that's what. Yeah, I Yeah. Yeah. Mhm. Um Guys, if you're in the main room here, please feel free to join the breakout rooms. Um It's the little tab on the left hand side. I think gender and Renee still have some space in theirs. Um So please feel free to join those groups. Ok. Ok. Ok. I'm gonna read out some names again for people to join breakout rooms. Um because there's still quite a few people in this main group chat and obviously that this is not where the practice is happening. So Aso Ahmed Ahmed. Um Bianca Dina Farina, Jesselyn, Jude and Laith. If you guys want to join Rim's breakout group, please. Um Because that's where the practice is happening. Um If you don't want to then feel free to leave the webinar because there's nothing happening in the main room now. And Mata Mara, Sad Eunice and Zain, if you guys want to join um gender's room, um then you can do the practice there as well.