respiratory

• 74-year-old male patient who presented with nausea and intermittent vomiting.

  'aching all over' especially in his back and limbs, feeling low (past months)

  lost 15kg in the past 3 months

  smokes 40 cigarettes a day for the past 60 years

  complains 'smoker's cough',

  explaining that sometimes his handkerchief is 'red stained'. 

  blood work: marked hypercalcaemia, anaemia and raised white cells. 

  Squamous cell carcinoma of the lung
• "stones, bones, abdominal groans, thrones and psychiatric overtones".


  hypercalcaemia
• weight loss in a short period, haemoptysis and his significant smoking history


  lung cancer
• PHC: "stones, bones, abdominal groans and psychiatric overtones" 

  Hx: very long smoking history

  Red flags: severe weight loss, haemoptysis

  Lung cancer + hypercalcaemia = PTHrP producing tumour in squamous cell carcinoma
• reduced level of consciousness, respiratory depression and pinpoint pupils and given naloxone

  opioid overdose
• opioid overdose

  give naloxone
• Opioid overdose resulting in respiratory depression. ABG:

  • PaO2: 7.5 kPa (56 mmHg)
  • pH: 7.31
  • PaCO2: 7.1 kPa (53 mmHg)
  • HCO3-: 24 mmol/L
  • BE: +1

  What does the ABG show?

  Respiratory acidosis (note:  respiratory depression has led to hypoxia, hypercapnia, and ultimately a respiratory acidosis.)
• ABG ranges:

  • pH: 7.35 – 7.45
  • PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg
  • PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg
  • HCO3–: 22 – 26 mEq/L
  • Base excess (BE): -2 to +2 mmol/L
• opioid OD with respiratory depression

  ABG: pH low, O2 low, CO2 high

  Acidosis, respiratory, secondary to type 2 respiratory failure
• 6 yo boy struggles to get out full sentences due to breathlessness (SOB)

  SpO2 90% on room air

  RR= 43, HR= 130

  O/E: cyanosed and fatigued, accessory muscle use as he breathes. Auscultation reveals poor air entry bilaterally.

  What severity of asthma does this child have?

  life-threatening asthma attack
• • Respiratory rate ≥ 25/min
  • Heart ≥ 110/min
  • Inability to complete sentences in one breath
  • PEF 33-55% best or predicted 

  acute severe asthma
• • PEF <33% best or predicted
  • SpO2 <92%
  • PaO2 <8 kPa
  • Normal PaCO2 (4.6–6.0 kPa)
  • Silent chest
  • Cyanosis
  • Poor respiratory effort
  • Arrhythmia
  • Exhaustion
  • Altered conscious level
  • Hypotension

  Life-threatening asthma (severe asthma+ above)
• • Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

  near fatal asthma
• ABG how to read?

  Hypoxia first is it respiratory (Type 1, norm CO2, type 2 high CO2),

  then acid (7.35) or alkaline (7.45),

  if pH normal, does CO2 look ew, if yes then there's compensation

  HCO3 same as pH?, what does CO2 say? is same direction then there's compensation. the metabolic?
• baby 3-6 months, flu symptoms, increased work of breathing (subcostal recession and head bobbing), can't keep feed down

  bronchiolitis with RSV (respiratory syncytial virus)
• child 6m-3yo, seal-like barking cough, worse at night, flu like symptoms 12-72 hours, swelling neck, may have stridor


  croup, parainfluenza
• 19 yo, 1 week high fever 38.9, muscle ache and diarrhoea. Chills and sweats, Uganda with mosquitoes,

  sausage-shapes gametocytes on thick and thin blood film

  Malaria,  P. falciparum parasite (lack of fever and sausage blood film)
• what malignancy asso with malaria?

  Burkitt's lymphoma (Erythrocytes infected with P. falciparum bind to B lymphocytes, causing uncontrolled cell differentiation when co-infected with EBV. This leads to Burkitt’s lymphoma, which particularly affects B lymphocytes in the germinal centre.)
• acute systemic infectious disease caused by an RNA paramyxovirus. 

  spread by respiratory droplets

  swelling of the parotid glands; the involvement of other salivary glands, meninges, gonads, and pancreas is also common. 


  mumps
• A 43-year-old male returns from a 3 month holiday in Zambia and develops a chronic cough associated with night sweats and ongoing weight loss. His chest X-ray reveals a right upper lobe cavitation and cultures reveal acid-fast bacilli with a Ziehl–Neelsen stain.

  TB
• 3-year-old boy A&E high fever and difficulty breathing. 

  sitting upright with his mouth open and drooling. He is working hard to breathe, with obvious stridor and subcostal recession.

  O/E: 39 degrees, RR 26, SpO2 94% on room air

  what could he have and what do you do?

  call anaesthetics/ ENT, possible epiglottitis

   fever, an upright sitting position, and drooling

  haemophilus influenza

  Do not stress the child (no throat exam)
• fever, an upright sitting position, and drooling, working hard to breath with stridor

  possible epiglottitis, call ENT/ anaesthetics
• infectious mononucleosis/ glandular fever cause?

  Epson-Barr virus (EBV)
• EBV associated with which cancers?

  Hodgkin's lymphoma, Burkitt's lymphoma, nasopharyngeal carcinoma and gastric cancer
• hairy leukoplakia and central nervous system lymphomas.


  HIV
• acute pharyngitis, upper respiratory tract infections,


  Adenovirus
• gingivostomatitis

   Herpes simplex 1
• genital herpes. 

   herpes simplex 2
• respiratory tract infections, particularly bronchiolitis in young infants.

  Respiratory syncytial virus
•  roseola infantum in infants.

  Human herpes virus 6
• Karposi’s sarcoma in AIDS

  Human herpes virus 8