GP placement

Question 1

What is Croup ?

Answer 1

Laryngotracheobronchitis - inflammation of larynx , trachea & bronchi caused by viral infection - Parainfluenza

COMMON CAUSE OF RESPIRATORY STRESS IN CHILDREN (typically affects 6 months to 6 year olds) - but can occur at any age.

CHARACTERISTICS

• Distinctive seal - like barky cough (can happen suddenly with no preceding illness )
• symptoms increase with agitation

MAY also have :

• hoarse voice
• Stridor
• respiratory distress
  (often accompany seal like barky cough)
• symptoms get worse at night
• abrupt onset

INVESTIGATIONS

• Clinical exam

consider :

X- ray anteroposterior and lateral neck
(Steeple sign - narrowed trachea)
- only do x ray it children who are presenting with atypical symptoms.

Question 2

Treatment of Croup ?

Answer 2

Mild (no stridor at rest ) -

0 Oral Dexamethasone (corticosteroid) + supportive care.

Moderate - stridor at rest , no agitation or lethargy

CORTICOSTERIOD + NEBULISED ADRENALINE (acting to relieve airway obstruction)

0 Oral dexamethasone
OR
- Nebulised Budesonide (corticosteroid) - if patient is vomiting , severe hypoxia or respiratory distress effecting administration of oral dose.

OR

IM dexamethasone

SEVERE - WITH STRIDOR / AGIGTATION OR LEGARTHY

0 same as moderate - only differences :

1. Can give IV dexamethasone - as a secondary option - beware that this can significantly increase agitation in a child with croup.
2. PLUS - Supplemental oxygen - blow by
   (if blow by does not work - non re- breather mask)
3. If impending respiratory failure
   ADJUNCT - Intubation (insertion of endotracheal tube through mouth into airway) - so they can be put on ventilation. (smaller sizes recommended due to possible subglottic oedema)

Question 3

Cerebellar infarct - GP ?

Answer 3

Patient no other symptoms just fell to one side -could not stop himself.

Commonly, about 75% of patients will report “dizziness” of some form, with a sensation of vertigo or of falling towards one side.

• has other symptoms

Cerebellar function

Question 4

What is Goodpastures’ syndrome disease ?

Answer 4

Known as anti-glomerular basement membrane disease
(anti-GBM)

CAUSE

Autooantibody to alpha-3- chain of type 4 collagen (found primarly in basement membrane of alveoli and glomeruli.

Autominmune condition, immune system attacks the basement membrane in kidneys, lungs leading to bleeding from lungs , kidneys failure and glomerulinephritis.

PEAK INCIDENCE BTW 20-30 YRS AND 60 TO 70 YRS.

CONSQUENCE

0 Pulmonary- renal syndrome - renal failure in association with respiratory failure.
PRS - consists of Glomerulonephritis & pulmonary haemorrhage.

SIGNS

0 Reduced urine output - Renal insufficiency

0 Haemoptysis - occurs in 60 % of people

0 Oedema
(if in lung - crackles)

0 Shortness of breath , fever , cough , nausea.

RISK FACTORS
HLA-DRB1 OR DR4

Question 5

Investigation of Goodpasture’s syndrome ?

Answer 5

0 Renal function test - abnormal

0 Renal biopsy - confirm diagnosis.
BEFORE THIS - DO CLOTTING SCREEN
(uncontrolled bleeding disorder , or uncontrolled hypertension - contraindication)

0 Anti - GBM antibody titre - positive.

0 Anti - neutrophil cytoplasmic antibodies (ANCA) - 30 -50% of patients also have these.

TO RULE OUT OTHER DIFFENTIAL DIAGNOSIS

0 Serum complement C3 , C4 - rule out Necessary to rule out nephritic syndrome related to lupus, infection, endocarditis, or cryoglobulinaemia.
SHOULD BE NORMAL

0 Anti - nuclear antibody - normal - to rule out lupus nephritis.

0 Hepatitis panel - Hepatitis b and C can cause renal disease
(hepatitis ——————–> glomerulonephritis———————————–> CKD —————-> Permanent damage)

0 Anti - streptolysin O titre - negative - rule out post-streptococcal glomerulonephritis.

Question 6

Treatment of Good pastures syndrome ?

Answer 6

REVERSIBLE RENAL DISEASE + ANY PULMONARY INVOLVEMENT

1ST LINE
ORAL CORTICOSTERIOD
+ PLASMAPHERESIS (to remove anti- GMB autoantibody)
+ Cyclophosphamide - supresses the immune system.
ADJUNCT - Prophylaxis for complications of high dose corticosteroids.
(e.g. osteoporisis , gastritis, pneumocystis)

WITH PULMONARY HAEMORRHAGE

Supportive measures e.g .

• supplemental oxygen ( if needed but avoided if possible - risk of hyperoxia , infection —————-> can exacerbate lung haemorrhage.

Cryoprecipitate & fresh frozen plasma - needed if coagulopathy develops.

should be advised to stop smoking

IRREVSIBLE RENAL DISEASE

• Supportive acre only