8. Haemoptysis Flashcards
Haematemesis
Brownish red blood that is vomited from the GIT
Epistaxis (nosebleed)
Particularly a posterior nosebleed
Bleeding gums
Combined with a cough this may be confused with true haemoptysis
TACE questions to detect alcohol dependance
Does it TAKE more than 3 drinks to make you feel high? (+VE=2 pts)
Have you ever been ANNOYED by people’s criticism of your drinking? (+VE=1 pt)
Are you trying to CUT down on drinking? (+VE=1 pt)
Have you ever used alcohol as an EYE-OPENER in the morning? (+VE=1 pt)
[Alcohol dependance = Total score of 2+ pts]
2 reasons why Haemoptysis is a red flag
- It may be the presenting symptom for life threatening lung disease
- Massive haemoptysis, variably defined as anything from >100mL to >1000mL over 24 hrs, may be life threatening itself, usu through asphyxiation but potentially also shock
Diagnoses to be concerned about- surgical sieve: INVITED MD - most COMMON CAUSES are infective
Infective Neoplastic Vascular Inflammatory Traumatic Endocrine Degenerative Metabolic Drugs
Diagnoses to be concerned about- INVITED MD
Infective: pulmonary TB, bronchitis, pneumonia, lung abscess, mycetoma
Neoplastic: primary lung cancer, metastatic lung cancer
Vascular: PE, left ventricular failure, bleeding diathesis (ie a bleeding tendency eg coagulopathy, severe thrombocytopenia), AVM, , vascular bronchial fistula
Inflammatory: granulomatosis with polyangiitis (Wegener’s granulomatosis), Goodpasture’s syndrome. SLE, hereditary haemorrhagic telangiectasia (Osler- Weber- Rendu syndrome), polyarteritis nodosa, microscopic polyangiitis
Traumatic: iatrogenic (post lung biopsy or intubation), wounds (rib fracture, stab injury)
Endocrine: (none)
Degenerative: bronchiectasis
Metabolic: (none)
Drugs: warfarin (bleeding diathesis), crack cocaine
Associated symptoms- What are you coughing up?
- Frank blood = vascular problem eg erosion of a bl vessel, ruptured AVM, vascular bronchial fistula
- Blood streaked sputum = any infection of lungs, in large volumes it’s bronchiectasis
- Frothy sputum = PO (2’ to LVF or severe mitral stenosis), can be bl stained so appear pink but rare
Associated symptoms-How much are you coughing up?
Quantify - teaspoon, tablespoon, egg cup or more
Associated symptoms-How suddenly did it start, and has it got worse progressively?
Sudden onset = PE, or erosion of cancer into pulmonary blood vessel
Gradual onset = Progressive cond eg bronchiectasis
Associated symptoms-Cough productive of sputum?
Indicates LRTI (pneumonia, bronchitis, TB) or bronchiectasis
Associated symptoms-Fever?
More commonly associated with LRTI. Night sweats may indicate TB.
Associated symptoms-Weight loss?
Associated with lung cancer and TB. Significant WL in short time is rarely result of diet and exercise so Ix.
Associated symptoms-Pleuritic CP?
Arise after PE or pneumonia that has spread to the pleura
Associated symptoms-SOB?
Quantify in terms of exercise tolerance; how far before SOB? stairs?
Sudden onset = PE
Gradual onset = HF
Associated symptoms- Haematuria +/or oliguria?
Some RARE conditions affect both lungs and kidneys (pulmonary-renal syndrome), the main causes =
- Goodpasture’s syndrome= AI condition where autoantibodies attack lungs + glomeruli in the kidneys. Imp to identify early since pt progresses rapidly to irreversible renal failure
- Vasculitides eg granulomatosis with polyangiitis - (+ve pANCA and nANCA) (Wegener’s syndrome), microscopic polyangiitis (+ve pANCA antibodies (more specific) as well as +ve nANCA), polyarteritis nodosa
- SLE (+ANA ABs)
PMHx- Smoking history?
Smoking = RF for Lung cancer. Calculate pack yrs (20 cigs = 1 pack)
PMHx- Exposure to asbestos or other inhaled industrial substances?
RF for Lung cancer = silica (stonecutter’s dust), coal, radon, arsenic, haloethers, polycyclic aromatic HCs
Asbestos = RF for mesothelioma
PMHx - prior lung disease?
Indicates chronic condition eg TB or bronchiectasis, or a vulnerability to repeated infections eg pneumonias
PMHx- Did he grow up abroad or travel recently?
If yes which country?
Vaccinated for TB? TB is endemic in many countries, particularly in the Asian subcontinent and southern African states and has reappeared in many eastern European countries since collapse of Soviet union.
Pts with TB can be relatively asymptomatic for extended periods of time
PMHx- Does he have RF for DVT/PE?
Includes prolonged STASIS (bed rest or long haul flight), BL VESSEL DAMAGE from recent trauma or surgery, MALIGNANCY causing hypercoagulable blood, other CLOTTING abnormalities, or a hx of previous venous thromboembolism
Also ask about a painful swollen limb, particularly leg, which could be a DVT leading to a PE
PMHx- Is he on anticoagulant meds or does he have a known bleeding diathesis?
Increases risk +/or magnitude of internal haemorrhage
Signs O/E - General inspection
Hoarse voice:?invasion of recurrent laryngeal n by cancer
Cachexia
Purpuric rash or petechiae:?vasculitis affecting lungs
Signs O/E - Hands
Clubbing:?Lung cancer, lung abscesses, bronchiectasis
Tar stains:?smoker
Wasting of the dorsal interossei:?invasion of T1 nerve root by apical lung cancer (Pancoast tumour)
Signs O/E - Arms
Hypotonic, hyporeflexive, weak arms:?hypercalcaemia due to bone mets from lung cancer
Signs O/E - Face
Swollen face:?obstruction of SVC by tumour
Bleeding from oral or nasal mucosa:?source of blood ie not true haemoptysis
Saddle nose:?granulomatosis with polyangiitis (Wegener’s)
Horner’s syndrome (miosis, ptosis and anhydrosis ie ipsilateral constricted pupil, droopy eyelid, and lack of facial sweating):?invasion of the sympathetic supply to the face by apical lung cancer
Jaundice: ?liver cancer which has spread to lungs or vice versa
Focal neurology: ?brain mets from lung cancer