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Gonna be doing this um talk on the unwell child here. It's kind of like a GP focused um uh presentation with sort of um Children presenting to Ed in various ways or not, sorry GP in various ways, um different symptoms and also kind of gonna focus on how to tell if a child is like particularly unwell and also how to differentiate between different conditions that might present similarly. Um and look for like um ways to differentiate between them that um are quite reliable. Um So just quickly, um a summary of what we'll go through today, we'll sort of talk about the nice traffic light system which you might have heard of um how to sort of assess a child or examine them and then um three cases um which can present with a lot of differentials um before summarizing. So hopefully we'll finish in about 40 minutes or something like that. So, um you may or may not have seen this um traffic light system of identifying whether a child is particularly unwell or not. Um It's um yeah, it's like a nice clinical know knowledge summary and it's used to stratify the risk of kids, um, attending GP and trying to realize, you know, which, um, aspects of a child's presentation are more concerning and you need to act on them, um, eminently and which ones, you know, you can either safety net and discharge or actually just fine. Um, so there's just a quick summary there of Green, just generally being, um, discharged home with advice. You know, it's not anything concerning if these are present. Um, it's more likely to be a mild illness or um something not to worry about. And then with Amber, um then you either do refer for specialist peds assessment or you discharge them with specific safety netting relevant to what kind of conditions that you're worried about. Um And then for red, um and then sorry for Amber as well, that kind of depends on what kind of uh um conditions that you're actually looking at, whether it's something that needs specialist follow up or something that can be prescribed um on a delayed prescription or something like that. And then red obviously is your emergency situations where you need to get them in the hospital as soon as possible. Um Yeah, so just to think about the examination of a child, I think with this um traffic like system, there can be like a lot of information on it that's pretty hard to pass. Um So one way of sort of getting around it is to sort of transpose it onto your aae assessment that you do um during your general pediatric examination. Um So I've just got some case like pictures here. This one is just like a cartoon but if anyone wants to drop in the chat or something like that, like what kind of sign is being exhibited um on this? Yeah, nasal flaring. Nice one. So again, this is um these are kind of um we're, we're looking at A and B here and we're looking at sort of signs of respiratory distress. So this one. Yep. So subcostal or intercostal recessions, depending on where you can see them. Um again, sign of increased work of breathing. And if we look at our sort of um um a respiratory section of our traffic light scheme, we can see the um moderate or severe chest indrawing. So the sort of um rece recessions and abdominal subcostal breathing um goes directly into red, whereas nasal flaring is not as bad, it goes into yellow. And then another key one is that grunting also goes di directly into red. Um because that could be a sign of like airway um um obstruction and then the numbers are a bit tricky to, to remember. But you know, if they are breathing at more than 60 breaths a minute, it's possible that they'll have some kind of chest indrawing and things like that. Um So it's kind of um a bit difficult to remember, but the the clinical signs are probably more likely to be what you'll be examined on. Um And then here's just another sort of um summary of that. So, yeah, nasal flaring is amber, but grunting puts the child straight into red. Um Same with chest indrawing and respirate over 60. And obviously, if you can auscultate, a wheeze um that suggests airway obstruction just as grunting does. So then if we look at circulation, we've got a few more signs. So um this is a bit of a, an abstract one. But can anyone think what this image might be trying to suggest? It's a bit of a rubbish image. So if uh if it's not clear, then it's probably my fault. Yeah, I can see why you'd say that um central cyanosis. Um What I was actually trying to go for is um just like a really dry looking mouth. So you can see that the tongue looks quite pale like Annabelle. Um noticed. So, um yeah, it's, it's more of sort of a lack of moisture and dehydration, which is what I was going for. So, yeah, that's a rubbish picture. So um no problem that that was a bit difficult here. Um What's being assessed for here? Yeah. Uh capillary refill time on which you do assess centrally on kids instead of on the finger. Um And again, you'd want that to be less than two seconds um in a healthy child. So, um we'll come onto it, but if it's um three or more seconds, then that instantly puts them in yellow and then here as well in this picture, can anyone, um, see what's being tested for or what kind of abnormality can be seen in this image? Especially if you look sort of down towards the iliac fossa. Yeah. So that's, that's like AAA pinch test for skin turgor. So he's like pinched some of the skin over the abdomen and held it there for about five seconds and let go. And then you can see that it's still sort of maintained that pinched shape and it's not like rebounded back to how it was before. So that's a sign of decreased skin turgor and in circulation, that's really the only one that puts you directly into red. Um The CRT, you know, no matter how long it is, it's only really gonna put you into yellow. But once you've got this decreased skin turgor that's um instantly read like instant specialist assessment or if it's, if, if you think it's life threatening, then 999. but there's quite a lot of things to remember here. Uh dry mucous membranes and reduced urine output are generally um good signs of like hydration. So if they are a bit dehydrated instantly, you wanna be a bit um more concerned. Um And thinking if there's something um bigger going on. So, yeah, there's just sort of a summary cos there's a lot of um information here, Tachycardia again puts you at most Amber. So even if they're, you know, flying at 100 and 80 that wouldn't be something where you'd be like, oh, this patient definitely needs to go into hospital, but if they are flying at 100 and 80 BPM, they're probably gonna have some other red sign um that you could um use to refer. Ok, so if we wanna look at um disability, this is kind of like your everything else um sort of stuff. So I've just got a summary slide here. Um So, uh in terms of how they respond to stimulation um that goes from green to red. Um And if they respond normally, green, if they respond abnormally ambers, so maybe if they're a bit more lethargic or they don't respond as actively as you'd hope. And if they literally are not responding to stimulation, then that's a red sign. And then again, with just sort of their level of consciousness, if they are um awake or they awaken quickly, then that's fine. That's a good sign. Um If they're a bit slow to wake um amber and if they literally are not staying awake, um even if you're constantly interacting with them, again, that's another red sign that they might be a bit more ill. And another one that you can always fall back on, I guess if you're uh worried is that just if, if, if you look at them and you think they're ill, like if you think they're like seriously ill. Um, when you're ever, um, clocking a child or something that's instantly like a red, a red flag thing. So, um, that's another thing to, to look out for and then e um, for exposure has got a lot, a lot of other stuff here. So I have a picture here of a kid's legs. Um, how would you sort of like, describe the, um, appearance of this kid's legs? Yeah, that's, uh, yeah, you can definitely say that it, it, it, it, it does look like a rash almost. Um, this is what I actually got. Yeah, exactly. So this is what I got when I searched up, uh mottled skin. So, um, it's pro, it's, it's quite a bad sign. Like it's, it's a sign that, you know, there's possibly some underlying sepsis or infective process going on. So I don't actually really know what it looked like before I looked it up. But, yeah, this is, um, essentially what bottled skin looks like. This is a bit of a crap picture. But can anyone tell what's going on here? Yeah. So the bulging Fontanel. So you can see if you look at the top of the kid's head, there's like the little, um, section where it's, um, pouching out. What would a bulging Fontanelle be a sign of? What kind of underlying pathology? Yeah, raised ICP. And then what sort of, um, what sort of conditions might be causing a raised ICP. It's like the main one that you'd be worried about. Yeah, meningitis. So, um especially if you're in a kid. Uh I think it's like 12 to 18 months is when the, when the anterior fontanelle closes. So any kid before then if you've got a bulging Fontanelle, that's quite concerning for some intracranial pathology such as meningitis. And then here um a sort of rash. How would you describe it? So this is kind of like your, your classic non blanching, um purpuric slash petechial rash, um which would be indicative of like meningococcal disease. So that's a nice area. Meningitis, sepsis is what causes this kind of picture and this is of course, um another red traffic light symptom. So yeah, that's just um the uh the section of the um the section of the traffic light thing that I was using. So if they're pale or mottled or ashen or blue, so any kind of skin color abnormality that you can see on exa examination instantly goes into red. And if the parent reports any of those things, then that goes into yellow, the bulging fontanelle alongside neck stiffness status and neurological signs and seizures are all signs of, you know, meningitis or encephalitis. So, those are all instantly go into red and um the the non blanching rash as well as a sign of meningococcal sepsis. So, um that um is a medical emergency and you need to uh treat that immediately and refer them immediately. Um Not refer even just 999. Another thing to be aware of is that if a child is younger than three months, um, and they have any kind of temperature above 38 degrees that's instantly red. Um, because you just want to rule out sepsis immediately. Um, the really young kids don't really have good other signs of sepsis other than just being febrile. So, um, it could be sepsis and therefore that's why you want to send them to the hospital straight away. Um, and then a few weirder ones as well is a long, long standing fever, a high fever in any 3 to 6 month old as well. That doesn't put you in red, but it does put you in yellow and also um, non, non weight bearing or swelling of a limb or joint is, is suspicious for things like septic arthritis. So they instantly go into um yellow and then they might have other signs that would put them into red as well. So again, just a summary, um, when you get the slides afterwards, just a summary for, um, for later. Cool. So, um, let's uh do some cases. Now, er, we'll try and get through them fairly quickly and I'll try to make it interactive because, um, I'm aware that uh, you guys, um, probably also know a lot about this, um, as well as me. So the first case is um, a two month old baby girl who's brought into your GP by her parents. Her parents are concerned that she's been very sleepy over the past 24 hours and is not feeding. Well, on examination, she seems quite pale and wakes briefly when stimulated, but goes back to sleep immediately. And some um, vitals that we have are, is that, um, her heart rate is 100 and 80 she's got a high temperature of 39.3. Um, obviously you might have some ideas as to what could be going on. But first of all, if you're taking a pediatric history with an unwell kid, can people put in the chart of what questions you might like to ask? Just so you get a full picture and these can be anything that you think is relevant. Yep. So that's a really good question. Um, how many wet nappies are you getting in a day? That's, um, a good sign of, um, hydration status. How long they've been unwell? Yeah, absolutely. You wanna have the, uh, the, the history clinginess is often a good sign of, um, how unwell a child is. So, um, often parents will sort of volunteer that by themselves again. Yeah. Um, drinking milk, recent infections as well. Often, um, the child that Children that are clinging might be a little bit more, um, old than this one, but it's definitely a good sign and yeah, the, the parents will often bring them up, bring that up themselves. Yeah. Feeding activity, infection symptoms. Yeah. Exactly all the symptoms you want to do a full systems review just to see if there's anything else, medical problems to date. Yeah, that's a good one as well. Um, just to see, um, if there's a history of infections, if there's anything that needs to be investigated further. Good. Yeah, thanks for putting everything in the chat guys. Cos there are some really good ideas in there that I didn't think of at as well. Yeah, exactly. Annabelle. So I was just about to come on to that pregnancy and birth history is really useful. Um And then things like um at two months old to be fair, you'd probably just about be coming up to your first set, first set of immunizations, but you'd wanna ask it anyway. Um and um I think it's like bins is the, the acronym. So um birth um as you said and pregnancy, I for immunizations n for any neonatal problems. So yeah, pick you or nicu admission like Tom said um D for development uh two months again, is not a huge amount of development that's happened and then s is like social history. So I'd always throw in some social history stuff like um you know, does anyone smoke at home? You know, have there any social service involvement at home? Um uh Any other Children at home who are ill, that kind of thing? So you just wanna get the full picture? Cool. Um So if I go on to the next slide. Um Oh, never mind. What is your next step? So if we think about using the traffic light tool or even just your own kind of gut feeling, what would you want to do in this situation? Yeah, that's pretty, that's a pretty good idea. Um Yeah, obviously this child seems super ill. Um And even just with your gut feeling, you might just want to send them to hospital straight away. But if we do also look at the um if you do look at the traffic light to, you can see the um just looking pale instantly puts you in um red because of color and then um not feeding. Well, uh I think maybe, yeah, OK. It doesn't have its own special thing but um not being um easily arousable and, and, and going back to sleep immediately is another concerning feature. Um So yeah, how many red do you have to have to send to A&E say amber? So just one. Yeah, I think it's, I'm pretty sure it's literally just one red sign and then you're like, yeah, this is bad. And for amber again, it's, it's, it's amber is a little bit more um uh debatable because it depends on the condition. If it's something that you can treat um at GP, you're like, ok, this patient clearly needs some antibiotics or something, then you do that. But if it's something that needs specialist assessment, then you need to to, to refer for that and, and get that sorted as well. It's only green, which is really just like, discharge without any, um, treatment. But obviously safety net has always, um, as any, as he always would in GP and especially for Children. Cool. So, if we, if we talk about this case, I can't keep this face in your mind because I didn't de de design the slides very well. Um, oh, another question. Sorry. Um, what investigations? So, let's say you're at Ed now and you're like the on call, Peds, emergency doctor or something. What investigations would you be trying to do to, uh, get to the bottom of what could be causing this? Yeah, that's a really good one. So, yeah, when you're suspecting sepsis, obviously you don't wanna do blood cultures and you don't wanna do your blood cultures before you start your antibiotics as well. Whole set of Arbs, bloods. Yeah, exactly. You wanna, you wanna do everything? So, when, when the child is this ill you don't wanna hesitate doing bloods just cos they're a child like, um, quite often in Ed or A&E if the kid is, you know, they're relatively well, they might be like, oh, we don't want to upset them and, you know, spend hours trying to get blood out of them in this situation. You do need to, you do need to do your, uh, your investigations even though there are, they are, um, almost a neonate Um So, yeah, and chest X ray and LP have indicated. Yeah, brilliant. So I've literally got that here. So this is kind of your like septic screen. A urine dip is, is another uh another easy one to do because they always have wet nappies and you can kind of like squeeze the urine out of them or something like that. There's some way of doing it. Um And then lumbar puncture, obviously, if you're suspecting things like meningitis, chest X ray, if you're suspecting AAA pneumonia, and obviously, um I've kind of done these the wrong way round, but um there's some differentials there. Um Obviously, if you're suspecting some kind of urinary symptoms, you'd wanna do your urine dipstick, but realistically, you do that for everyone. If you're suspecting pneumonia, you'd wanna do your chest X ray. You'd still want to probably do your blood cultures. Um And you might be suspecting a pneumonia if the child is in severe respiratory distress. As they've got the intercostal recessions, they're grunting. They've got um, you know, nasal flaring all those kind of things. Um, meningitis, you might be suspecting if they've um, had a fever if they've got any focal neurological signs, um, any neck stiffness, probably you're not gonna notice that in a two month old. But yeah, obviously, you guide, you use your differential diagnoses to guide your investigations. Um and also, um to think about some non infectious causes that could also present in a febrile child. Um Kawasaki disease is one will sort of come on to that a bit later. Um, and also juvenile idiopathic arthritis, which can also present with a fever and a, and a arthritis type picture. This is kind of like a widespread of differentials. You wouldn't necessarily get these in such a young kid. Um But I've just had um the, the, the sources for this kind of stuff. I'll, I'll put it in the notes of the slides. Um So you can read up on that uh when you get the slides afterwards. Cool. So let's pivot to a different case now, which is like a child with a rash. Um So this case is of a three month old boy, three year old boy, sorry, brought to his GP by his dad. Uh Dad says he's been a little bit feverish and had a runny nose for the past three days. He also reports that a rash has also developed, which started on his face but has now spread to his chest. His temperature is 37.8 °C. So, what additional questions would you like to ask in this boy's history? Yeah. Really good idea. So, yeah, ent stuff. So um ear pain discharge cough. Yeah, is really good. So you're, you're trying to figure out if there's like some kind of viral illness or is it more bacterial if it's like a productive cough? Yeah, contact would be really helpful because that would instantly help you, you know, kinda get to the bottom of what might be going on if there's any um uh close contacts who have already been diagnosed. Any other ideas? Literally just put anything in the chat and try and make it kind of like a discussion rather than me, just sort of speaking. Yeah, vaccination history is really good Tom. Yeah. So again, you always wanna ask that B IND S immunizations, you wanna ask that? I saw a, a case in GP today where there's a patient who had recurrent respiratory infections but also had no vaccination history. So you know, that instantly opens up more differentials that you wouldn't consider usually because if you just assumed they were vaccinated and yeah, look in the mouth. So yeah, that's a good idea. You're looking for those um um other signs of viral infection or just inflammatory conditions such as Kawasaki. Um And yeah, with kids generally, if they've got kind of upper respiratory tract infections, you always wanna look in their mouth, look in their ear um because it's all kind of connected and you can usually um get more information. Um Yeah, good. Um Point from Lauren as well. Is it non blanching? So you wanna get all the information about the rash? So obviously you'll examine them. I probably should have um probably should have uh um phrased it such as what would you like to ask in the history and what would you like to examine? Um So non blanching. Um You know, how big are the uh what, what, you know, what's the nature of the rash? What does it look like? How has it changed over the past three days? Um um Yeah. Is it like vesicular? Is it macular? Is it discharge? Is it weeping? What color is it like? There's so much stuff you can ask for a rash and just examine yourself. How high is the fever? Yeah, it's a good one. So, yeah. Is it objective? Has he measured the fever or does you know the boy say he's feeling hot, cold and yeah, weather reon response to antipyretics is a really good um uh question as well. I didn't think of that one. So yeah, thanks for putting all the things in the chat as well because it's just like everyone has their own like good ideas and stuff. So it's really good to like share them all so that you can like, yeah, you get more than one person's opinion and, and priorities. So, yeah, thanks for that guys. Um So yeah. Uh So I'd I'm gonna put, how would you manage this? But first I'll sort of ask like how, what um differentials are people coming up with. So if I say that this, this when you saw the rash, it, it was a, it's a maculopapular rash. So that's to say macules correct me if I'm wrong. But macules are like um they're flat lesions. So, um, they're not raised, they're just sort of coloration on the skin and then papules are when the same things, but they become raised. So it's like a maculopapular rash. I think that's right. If I'm wrong, please correct me. Um, and it's, yeah, it's, it's on the cheeks, but it's also spread down onto the torso now and the fever is, um, it's not a high fever. It, it might not even be a fever. It's, it's 37.8 degrees and just generally, he's been a bit irritable and um clingy and maybe slightly decreased urine output. So, yeah, good ideas. Chicken pox. Yeah, it could be chicken pox could be measles rhinovirus. Yeah, upper upper respiratory tract infection. Definitely. You can actually, yeah, you can get a reactive rash just with the normal cold. So that's a good um suggestion. Any other ideas at all or I can move on the whole kind of point of it is that there are a load of differentials for this. So that's why it's difficult. Um And II, I'll try and run through some ways of sort of telling them apart in a moment. The one that I was trying to make this case about has not been mentioned. So that's probably a an indictment on me. That's fine. We'll just move on. Um Yeah, meningococcal meningitis is a good idea. So um necessarily it, you'd, you'd I think classically the rash for meningitis er starts on the legs or it is most obvious on the legs, but you could definitely get it on your torso. Um, I probably think the symptoms might be a little bit, um, worse cos meningococcal disease is very severe. It's like a very aggressive bacteria, nicer meningitis. And, um, you'd probably get meningococcal disease as in, like, you'd be septic before you had meningitis due to it. Um, so I think the, the kid would probably be a bit more unwell, so he'd probably be quite lethargic, more febrile. Um And um if he was specifically, if he had meningitis, he would probably have more sort of neurological signs, he'd be photosensitive, have neck stiffness. A a at the age of three, the kids can start to sort of mention these kind of things because they're more aware of them. Um But yeah, so um we'll also go on to the next case. Um interesting that you mentioned meningococcus because um this is the next case. Uh Yeah, anyway, you kind of pre empted me. Um But yeah, this is more of a classical rash that you'd see on um in meningococcal disease. Um you might notice it's a bit of a crap picture as well. And to be honest, I'm not even sure if this is the leg. I can't, I genuinely can't tell what body part it is if anyone has any ideas, let me know. Um But you can see that there's like these small um pete eye um, and they're not that dark yet, but if I go all the way back, um, here it can sort of develop to this, which is where you've got the longer, larger sort of splodges of, of, of what is blood, it's literally like bleeding into your skin. Um, because of, um, the septicemia, having the nice area of meningitis, bacteria in your blood, um, causes that and it starts off very pinprick and petechia like that. And then it sort of over time if you miss it and you don't treat it, they'll come back and they'll be like, oh my goodness, this rash is so much worse. My child is so much more ill. So if you ever see a rash that's quite, and it's like, um, early stages like this, you wanna be concerned and obviously they'll be ill with it as well. So they'll be lethargic and they'll also be more, more febrile um, than, um, with the previous case. Um, so again, um, I don't really need to talk about what other questions you'd ask, ask. Um, but if you do suspect meningococcal sepsis, what is your immediate management or what, what is your next steps if you are in GP? And if you have any questions about what I just clumsily tried to explain, do put it in the chat, I'll try and clear it up. Yeah, exactly. So if you're in GP and you see meningococcal sepsis, you want to give immediate injection of im benzylpenicillin and you wanna call 999 and get that kid to the hospital straight away because, um, meningococcal sepsis is like mega sepsis. Like it's, it's super bad. So, you want to, yeah, you, you wanna treat that with what you can in GP, first send them to hospital and then when they get to hospital, does anyone know what will be the first line kind of medication that they'll get for that at three years old? Yeah. IV. CefTRIAXone. Yeah. Exactly. And if, if that you were suspecting an potential encephalitis at the same time, so, maybe the meningococcal example is not the best because it'll be obvious if it's meningococcus. But if you send them to the hospital with suspected meningitis, maybe encephalitis as well. What additional drug would you prescribe if you, if they had potential encephalitis? Exactly. Yeah. So, viral encephalitis is the most common, um, enterovirus is, is the most common cause of encephalitis. And then I think HSV, I'm not sure. Maybe to, uh, I can't remember. You might want to check that one. But, yeah, if you want to cover for anti, um, cover with antivirals for viral causes of, um, encephalitis. And if, um, in what sort of symptoms would you be thinking? Or maybe there's an encephalitis picture here instead of just a meningitis. What additional symptoms would make you suspect that? Yep, seizures. That's a good one. Yeah. Any others at all. Maybe two more P one. Yeah, confusion. Yeah, focal neurological science is, is is good as well. Yeah, confusion. Absolutely. Yeah. So seizures confusion and also um decreased level of consciousness as well was another one that you could potentially throw in there? Cool. So that's really good. Um Nice. Ok. So yeah, the rashes are really hard to tell apart. So I'll I'll quickly sort of go through them and obviously people can sort of suggest there um ways of telling apart the rash as well. Cos that would be pretty helpful just to discuss between everyone. So let's say it was chicken pox. Does anyone have any ideas for things that are like specific to chicken pox that can help differentiate from other kind of rashes? So the rashes that we're talking about are these like viral exanthems which are just like, uh I think it just means like it's a rash associated with a viral illness and most of them are very mild. They don't need any kind of specific treatment. They might need a little bit of school exclusion. And then um specifically uh what are the sort of hallmark signs that differentiates it from other viral exanthems? Yeah, brilliant. So, um yeah, starts on face and moves the trunk. So that is uh that does narrow it down, but there are a few that do that. But yeah, exactly like Annabelle and Lantz said it, it, it becomes macular popular and then vesicular. So it has the additional stage of becoming um, fluid filled. Um And then once the fluid sort of, um so once the vesicles kind of pop, then they start to cross over. Um So that's like a specific thing that happens in chicken pox and doesn't happen in um other ones. So what have I put here? I can't even remember. Yeah, pretty much so. And also that you get the fever before the rash, rash appears. So there's that kind of temporal uh distinction as well. Um Cool. So what about hand foot and mouth disease? Does anyone have any specific ways you could differentiate that from other rashes? Yep. Nice one. Yeah. So it's pretty self explanatory uh distribution is in your hands uh on your hands. So like on your palmar surfaces um mainly on your feet, it can kind of be like around your ankles like around your uh medial malleolus. They can. Yeah. And then um in and around your mouth as well. And another way to differentiate this is this is also one of the few ones that's vesicular as well. So um chickenpox and hand foot and mouth, you get vesical formations of fluid filled um um aspects to the rash. Whereas for the other ones, it's more so um just the macules or papules. So, yeah, that's basically that. What about for slapped cheek? Which is Parvo virus? Any suggestions for that? Yeah, pretty much. Yeah. So if, if you ever get a question stem, that's like rash, erythematous, rash, like just affecting the cheeks. Then it's, it's, it's gotta be this because there's, there's not really anything else that does that. Um So yeah, and the last one is Roseola Infantum. Um which is human Herpesvirus six. Any suggestions for what could because uh well, how, how that is differ, differs from other rashes. It starts around the ear. Uh I don't know if I have that one. I'll see. I II can't, I can't remember what I put. So it's as much of a surprise to me as it is to you guys. Any other suggestions? I genuinely can't remember what I put. So we'll find out that's fine. We'll just see uh high fever followed by rash, febrile, convulsions may occur. So, um I think again, this has a distinction where you have your fever first and then your rash comes up. Um I think it's similar to the others where you have a rash that starts on your face and moves to your trunk. Um But I think there's like a 15% rate of febrile convulsions um with roseola and phantom. So if they ever mention there's like a viral exanthem, so uh a rash caused by a viral illness kind of picture, but they also had a sort of self limiting generalized tonic clonic seizure. Um then it's probably human Herpesvirus six because I think it's, it's way more associated with that one than others. I I'm not sure about the starting around the ear. Um It, it could well be true. Um So if that's another one, then that's a, it's a good, it's a good differentiator cos. Um, yeah, not all of them do that. So, there are a few more where, um, they are viral exanthems. So again, they're the rashes associated with viral infection, but these ones are a bit more serious and you might want to, um, sort of investigate further or treat them directly. Rubella stars upon the air. Huh? So that's what I have for measles that it starts behind the ear and it also has a couple spots that you mentioned earlier. Um This, so yeah, I'm glad that it's proved my point about them all being difficult to tell apart, but it's not very helpful that they're still little difficult to tell apart when I'm trying to teach on it. So, what I had for measles was that it starts behind the ears and it goes to the trunk and you also have these clic spots in your mouth which are like these really tiny little white spots. Um Oh, great. Ok. Well, my uh information was from Pass me me which is obviously more reliable than NHS. So um No. Yeah. Um mm So maybe that's not the best um differentiator between measles and rubella. Um But maybe the K spots is, is a good um a good differentiator cos as far as I know that doesn't happen in rubella um If anyone has an, does anyone else have any good ways of differentiating between measles and rubella that uh they wanna share? Because mine has just been tossed to the ground and trodding all over while people are, are thinking of that. I'll also touch on eczema hepaticum. Um Eczema hepaticum is um a herpes virus infection of um people who most usually have already have an eczema rash. So if you have a history of eczema, that's kind of like a key indicator that it could be this. Um Again, you have these like punched out lesions, so they are raised and they're kind of like hollowed out in the middle. So that's, that's kind of specific to this. And also this one is um notoriously painful. So the other rashes aren't necessarily as painful as, as this one. And eczema herpeticum is like a medical emergency. They need to be admitted and given acyclovir because um they can get very ill, very fast with that. Um measles and rubella. I think obviously you'd have to not be vaccinated to get this in the first place. Um So I think it's, it's kind of treated supportively and contacts are offered the vaccine. Um And then you sort of exclude from school for a bit um while you get over your illness. Again, if, if, if anyone has any suggestions for differentiating between measles and rubella, please do share them. But if not, maybe we can look it up um at the end when I'm finished. Ok. So there's um only one more case. Uh oh, never mind. I've got more of this. So Kawasaki disease, um scarlet fever and the petechial rash are causes of rashes that are not viral or in the case of Kawasaki um disease, they're not infectious even. Um does anyone have any kind of Hallmark features of Kawasaki disease? Um which would help you differentiate it from other um rash forming conditions? Yeah, exactly. Crash and burn. So um I can't remember exactly what it stands for, but burn is a really high fever, I think for four or five days. So that comes first. Um And then yeah, strawberry tongue. So I think that's the s um so the five that you have a a high fever for five days, that's not responsive to paracetamol and antipyretic pyretic and things. Um Thank you, Annabelle. Yeah, conjunctivitis, rash, cervical lymphadenopathy, um strawberry tongue and also desquamation, the peeling of the hands and feet. Um And yeah, so that's what I have here. So it's your, it's if you, if your fever starts to last over five days, I think that's when you start to get suspicious that it could be Kawasaki disease, especially if it's not um responsive to uh paracetamol, strawberry tongue, salical lymphadenopathy and also the de formation of your hands and, and and soles. Um anyone aware of like the the complication that can arise as a result of Kawasaki disease that um past med loves to ask about a support us. Yeah, coronary artery aneurysm. So, um that's uh something that can happen because it's a, it's like a vasculitic, a vasculitic condition. So, um I think coronary arteries are most commonly affected. So you wanna do an echocardiogram to check for coronary artery aneurysms. Ok. Scarlet fever is kind of like, I think it's taught a lot nowadays if you're on the wards, like people always tell you the things to look out for. It can also be confused with Kawasaki disease. I think they both have a uh um they both have quite a similar presentation and very different treatments. So anyone um got any ideas for scarlet fever while the sort of key features like strawberry tongue again. Yep. So that's, that helps you sort of narrow it down to scarlet fever or Kawasaki. Anything that's sort of present in scarlet fever that you wouldn't see in Kawasaki that you can use to differentiate between the two. Yeah, short of fever. So I think it's usually the, the fever is 1 to 2 days instead of five and um the sore throat and inflamed oropharynx, you might see exudate on the tonsils and things like that. Um Those are, those are your kind of differentiating features. And then the last thing we discussed is the petechial rash. And the, the, the main thing here is that it doesn't blanch with pressure. So that's your non blanching rash. Um And that's because it's literally just like blood that's in your skin. You can't like squeeze it and make it go away. It's, it's gonna be there. Um And obviously you'd be worried about meningococcal sepsis, but it could be anything um, that causes you to bleed abnormally. So that's immune, um, idiopathic or immune thrombocytopenia. Um Henoch sle purpura, which is another vasculitic condition could also be hemolytic uremic syndrome. So, um there's even some wide differentials for that as well. So you'd want to use your other clinical signs and history taking to, to narrow it down. So w we've got 10 minutes left. So we'll try and a bit through this last one quickly. It's sort of a um another case but more of a re rest focused uh the acronyms. So it was just a, it was just if you go up, it's um uh yeah, it's just crash and burn for, for Kawasaki disease. So it's, it's like um it mentions all the, the symptoms that are um indicative of, oh IP HSP. Ok. Sorry, sorry. Uh So ITP is immune thrombocytopenia. Um It's a condition where you, you have a recent um viral infection usually in the last week or so and it causes autoimmune destruction of your platelets. So your platelet count drops really low and because of that you just start to bleed. Um It's actually pretty innocuous condition because it's just sort of triggered um by your viral infection um but it, um it presents with the same kind of rash as you'd get in meningococcal sepsis. So, if you see it, you still need to treat it as meningococcal sepsis un until proven otherwise. And the way you do that is you just do a, a full blood count. And if the only thing that's wrong with it is the platelet count and there's no other sort of fever or any of the red flag signs, then you're fine. It's probably ITP HSP is Henoch Purpura. Um It's like some guy's name and purpura means those big blotchy rashes. Um That is a vasculitis condition. Um That yeah, again, causes bleeding into your skin. H US is hemolytic uremic syndrome. I think it's associated with a specific type of E coli um sero variant like 0157 H seven or something like that. Um So yeah, um I'll put that in the notes as well for the slide so that you can um you can read uh the full names of those. Cool. So um to go on to the final case. So you've got a three year old boy who presents to your GP practice. He's been coughing profusely for the past couple of nights and after a bout of coughing, he makes a sharp high pitched noise on inhalation. I don't know why I wrote the case like this. It sounds like a three year old boy walked into your GP practice by himself. And produced this wonderful history for you. But I think I was just getting a bit lazy near the end. Sorry. So, um, if we have a presentation like this, what are your conditions that you're thinking of investigating? Yep, Croup is a good one. Anything else? Foreign body? Yep. So once you, once you're thinking of the sharp, high pitched noise, you're, you're, you're going down the Stridor route. So you'd be, you'd be worried that there's something obstructing the airway. Yeah. Croup. Yeah, I tried to make it less, obviously, Croup by not using the words um, barking cough, but it seems like it's, it's led you guys that way as well. Whooping cough. Yeah. So again, that's another one that can quite commonly be confused, like sort of, you know, is it croup, is it whooping cough? Um Obviously there's a vaccine for it. So if you asked about immunizations and they are not up to date with their immunizations, then um maybe you'd um think that it could be whooping cough, I think also whooping cough can affect younger kids. Whereas croup is more like a toddler age group, epiglottitis is a really good one as well. Um With a Stridor as well, you always want to rule that out. Again, the immunization history is very useful because um there's the Haemophilus vaccine, I think. Um so and epiglottitis is quite commonly caused by haemophilus influenza. Um There is a vaccine for haemophilus, right? But yeah, so absence of vaccination history then you'd be like, oh, could this also be whooping cough? Could it be, um, could it be epiglottitis because of haemophilus? Um, yeah, hib vaccine? Yeah, that's the one, any other ideas? We've got quite a few already. So, it's all right. If not. So, if, if, if we run with Croup as our top differential does they wanna know what the first line kind of management for that is? Yeah, dexamethasone, single dose. Yeah, you know, the the dose per kilogram as well, which is very impressive, nice one. And also cool. That's there's nothing else um for that case. So again, there's a few conditions here which, you know, they all present with this wheezy loud breathing kind of unwell coughing child and it's quite hard to tell between them and they all have quite different management as well. So I was wondering again, if we could kind of do a discussion as to how would you differentiate between these kind of conditions? So we've, we've talked about Croup already. It's your barking cough. Um Again, it's kind of a, it's kind of a weird one because I don't think I've ever seen anyone refer to it like that in real life, but in all the questions and stuff, it seems like that's the terminology they use. And you've also mentioned the dexamethasone as the first line management. If we go on to talk about, uh if we go on to talk about epiglottitis. Um, anyone know any sort of key features where you'd be suspecting epiglottitis over anything else? Yeah, drooling. So, um, just like keeping the mouth open all the time. Lots of inflammation and the tripod stance. So, trying to maintain their airway just because there's at such risk of getting blocked by the, um, by the inflamed epiglottis that they just be hunched over, like, literally all of their like energy just being put into trying to maintain the airway and breathe. And that one is a medical emergency. You need to um, 999 straight away, get an ent referral in any other differentiators. It's all right. We're running out of time, so I'll just kind of go quickly. Um Yeah, tripod high fever and unvaccinated as well. And that's another sign anyone know where the management is for, for this uh f clots. I think I kind of just mentioned it. So it's urgent admission. Um ent referral airway support, but ent will sort that out and then also antibiotics as well to treat the Yeah, exactly. Do not look in the mouth. Don't, don't do an airway inspection cos by moving them or, you know, shifting them. You might just make things worse, bronchiolitis. Any ideas for um any differentiating features of bronchiolitis from the other respiratory infections? Yeah. So the crackles uh is, is, is pretty good for bronchiolitis and yeah, younger Children as well. So that's a, that's kind of how I go off it if there's ever a question and you have to pick between them. Um, yeah, so less than one year old off food, dry cough and, you know, the crackles are good as well. I didn't mention them but I'll try and add them in maybe because, um, that's a, that's a good point. Um, and management of bronchiolitis. It can vary. Uh, does anyone know anything specifically about that? Yep. Supportive care. mostly. Um The only time you would differ from that is if their sats are low, if they're particularly off their food and um, if their respirate is really high, there's like a few criteria where you wanna be a bit more, um, careful, you might wanna admit them to hospital and make sure that they get um, some more oxygen supplementation. Um Again, you might wanna look that up. Um And then I'll just go quickly through these inhaled foreign body. You're looking more at the Stridor, they might have a cough as well and it'll be really sudden onset cos obviously they would just inhaled the thing straight away. Um And you wanna get that out. So you want to send them to the hospital so that can be removed, um, acute asthma exacerbation. The main thing here is the wheeze. Um So you wanna auscultate for that expiratory wheeze. Um Whereas Stridor is usually an inspiratory noise, wheeze is usually expiratory. So that's, that's um one way to differentiate them if you can't differentiate the sound and also a history of atyp. So they have like a nut allergy or dust allergy. And if they have eczema, things like that, they're hay fever as well, they're more likely to have um asthma. Um And then there's, I was just put nebuliser albu here, but obviously there's a whole ladder for asthma which I'm sure you guys um know or, you know, are in the process of learning anaphylaxis again. Um the wheeze but you also get s more systemic signs. So you'll get a skin reaction, you'll get swelling or angioedema. Does anyone know the doses for um adrenaline in Children to treat an anaphylaxis? It's all right. If not, it probably even if you didn't know it would take ages to, to to write it out. So 0.3 mg. Yeah. So I think it's, it's 300 mcg. So yeah, it's 0.3 mg and it, it differs per age. So I think in over twelves, you're basically an adult. So you can have 500 mcg in 6 to 12. I think it's 303 100 mcg like you said, and then 0 to 6, it's 150. So you kind of like half it kind of from 500 to 300. I know that's wrong. Um When you halve yourself from 12 to 6. So 6 to 12 is 300 then you do it again for the 0 to 6 and that's 150. Uh, that, that kind of makes sense to me but now that I just sort of vocalized it, I realize how bad it is. Um, and it's 1 to 1 to 1000 adrenaline. I think. So. I think it's 1 g in, or is it one in 10,000? I'm gonna look that up quickly. Um, and then for, uh, for 1 to 1000. So, yeah, I think it's 1 to 1000 and then for, uh, pneumonia, um, bronchial breathing is the main sign. So if you listen, you'll hear the, you know, the air entry, you don't get that nice, like balloon inflating sound. That is vesicular breathing. You'll get a sound kind of like if you're like blowing through like a, a toilet paper tube or something like that, if that's something you do, um, it would be more like a harsh sound of air blowing through a tube rather than the nice balloon inflating sound. And also you'd have an associated fever and you treat it with antibiotics, uh, and fluids. Cool. So that's the end. I hope that was useful. I didn't really want to go through each and every condition because there's just so many of them to like, cover individually and go through all the symptoms management, everything like that. I was hoping that it would be useful just to sort of like, discuss between everyone who's, who, who turned up like, um, what are the ways you can differentiate between the diagnoses and what sort of key features in the history you might be looking for such as even things like immunization, history and, and things like that. Um So I hope it was helpful if anyone has any questions or things like that. Um um Please do ask um and there's the QR code for the, for the, the feedback link and um I've not put the slides up yet, but once I add all the stuff that people asked for, um, I'll give them to James and I'm sure he'll sort out.