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Oxford clinical cases > Haemoptysis > Flashcards

Haemoptysis Flashcards

1
Q

What might haemoptysis be confused with by the patient?

A
  1. Haematemesis: brownish-red blood that is vomited from the GI tract
  2. Epistaxis: particularly a posterior nosebleed
  3. Bleeding gums: combined with a cough, this may be confused with a true haemoptysis
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2
Q

What are the TACE questions used to detect alcohol dependence? How is it scored and how do you interpret the score?

A

T: Does it take more then 3 drinks to make you feel high?
A: Have you ever been annoyed by people’s criticism of your drinking?
C: Are you trying to cut down on your drinking?
E: Have you ever used alcohol as an eye-opener in the morning?

A positive response to the first question scores 2 points and a positive response to the rest scores 1 point. A positive response to two of these four questions is considered to indicate possible alcohol abuse, as well as a score of two or more.

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3
Q

What are the 2 main reasons why haemoptysis should be investigated thoroughly?

A
  1. It may be the presenting symptom for life-threatening lung disease.
  2. Massive haemoptysis, >100ml to >1000ml over 24 hrs, may be life-threatening itself, usually through asphyxiation (suffocation, deprivation of O2) but potentially also shock.
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4
Q

What diagnoses should you be concerned about with haemoptysis ? (INVITED MD)

A

INVITED MD

Infective: TB, bronchitis, pneumonia, lung abscess, mycetoma
Neoplastic: primary lung cancer, metastatic lung cancer
Vascular: PE, left ventricular failure, bleeding diathesis (tendency e.g. coagulopathy, thrombocytopenia), arteriovenous malformation, vascular-bronchial fistula
Inflammatory: Goodpasture’s, SLE, granulomatosis with polyangiitis, hereditary haemorrhagic telangiectasia,
Traumatic: iatrogenic (post biopsy or intubation), wounds (rib fracture, stab wound)
Endocrine: NONE
Degenerative: bronchiectasis
Metabolic: NONE
Drugs: warfarin (bleeding diathesis), crack cocaine use

The most common causes are infective.
Lung cancer is a ‘must exclude’ diagnosis in the presentation of haemoptysis
Up to 1/3 of cases do not have an identifiable cause

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5
Q

Frank blood, blood-streaked sputum and frothy blood. What are each suggestive of?

A

Frank blood: Vascular problem e.g. erosion of a blood vessel (invasive cancer, bronchiectasis, TB), vascular-bronchial fistula

Blood-streaked sputum: Any infection of the lungs, but in the context of large volumes of sputum this would suggest bronchiectasis.

Frothy blood: pulmonary oedema (secondary to e.g. left ventricular failure, or severe mitral stenosis).

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6
Q

What is sudden onset of haemoptysis consistent with?

A

Sudden onset is consistent with pulmonary embolism or erosion of a cancer into a pulmonary blood vessel.

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7
Q

What does gradual onset of haemoptysis suggest?

A

Bronchiectasis (a progressive condition)

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8
Q

What are 3 main questions you should initially ask a patient presenting with haemoptysis?

A

What are you coughing up? (Frank, frothy etc)
How much are you coughing up?
Hoe suddenly did it start and has it got worse progressively?

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9
Q

what does a cough productive of sputum indicate?

A

Lower respiratory tract infection (pneumonia, TB, bronchitis) or bronchiectasis

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10
Q

What is fever more commonly associated with?

A

LRTI.

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11
Q

What might night sweats indicate?

A

TB

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12
Q

What does weight loss generally indicate?

A

Unintentional weight lost in a short period of time indicates lung cancer or TB.

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13
Q

What does pleuritic chest pain indicate?

A

Following a PE or pneumonia that has spread to the pleura.

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14
Q

What do sudden-onset SOB and gradual onset SOB suggest?

A

Sudden-onset: PE

Gradual: HF

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15
Q

Why is it important to ask if the patient has had haematuria and/or oliguria (production of abnormally small quantities of urine)?

A

There are a number of rare conditions that can affect both the lungs and the kidneys:

  1. Good-pastures syndrome (autoimmune condition whereby autoantibodies attack the lungs and the glomeruli in the kidneys –> irreversible renal failure)
  2. Vasculitides (inflammation of a blood vessel or blood vessels) e.g. microscopic polyangiitis, granulomatosis with polyangiitis, polyarteritis nodosa
  3. SLE
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16
Q

What is the most significant risk factor for lung cancer?

A

Smoking

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17
Q

What are some risk factors for DVT?

A

Prolonged stasis, blood vessel damage from recent trauma or surgery, malignancy causing hyper coagulable blood, other clotting abnormalities, history of previous venous thromboembolism. Ask about a painful swollen limb.

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18
Q

What could you detect from a general inspection from end of bed?

A
  • Hoarse voice (tumour invading recurrent laryngeal nerve)
  • Cachexia
  • Purpuric rash or petechiae (vasculitis affecting lungs)
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19
Q

What could you detect from inspection of the hands?

A
  • Clubbing (lung cancer, lung abscesses, bronchiectasis)
  • Tar staining
  • Wasting of dorsal interossei (tumour pressing on T1 nerve root - pancoast tumour)
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20
Q

What could you detect from inspection of the arms?

A
  • Hypotonic, hypo reflexive, weak arms? HYPERcalcaemia due to bone metastases from lung cancer.
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21
Q

What could you detect from inspection of the face?

A
  • Swollen face (obstruction of superior vena cava by tumour)
  • Bleeding from oral or nasal mucosa?
  • Saddle nose? Granulomatosis with polyangiitis
  • Horner’s syndrome (mitosis, ptosis and anihydrosis), invasion of sympathetic supply to the face because of apical tumour
  • Jaundice? Liver cancer which has spread to the lungs or vice versa
  • Focal neurology: lung cancer metastasised to the brain
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22
Q

What could you detect from inspection of the neck?

A
  • Cervical lymphadenopathy, non-tender: TB, bronchial carcinoma
  • Virchow’s node: GI malignancy which may have metastasised to the lungs
  • Tracheal deviation? Pleural effusion due to cancer? Lung collapse secondary to a large mass such as a tumour or abscess?
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23
Q

What could you detect in the abdomen?

A
  • Hepatomegaly: liver cancer metastasised to the lungs and vice versa
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24
Q

What could you detect in the legs?

A
  • Unilateral signs of DVT which may have caused a PE.
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25
Q

What could you detect in the chest?

A
  • Asymmetrical lung expansion: lung pathology in affected side?
  • Dullness to percussion: pneumonia, lung abscess, malignant pleural effusion
  • Stridor?: Tumour or foreign body obstructing bronchus
  • Crackles? pneumonia, left ventricular failure, bronchiectasis
  • Pleural rub: mesothelioma, pleuritis from pneumonia
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26
Q

In a patient with sudden weight loss, haemoptysis and hepatomegaly, what investigations would you perform?

A
  • Oxygen saturations (helps you understand the severity of the underlying disease)
  • Blood tests (FBC for anaemia or raised WCC, CRP raised in infection, inflammation and some malignancies, clotting screen, U&Es for renal involvement, Calcium, phosphate and ALP for bone metastasis from a lung cancer, liver enzymes for involvement of cancer)
  • Urine test: urinalysis looking for haematuria suggesting pulmonary-renal syndrome
  • Imaging: Chest radiograph

NOTE: If TB is suspected, strenuous efforts must be made to obtain specimens or tissue to culture the organism.

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27
Q

What signs would you be looking for on a chest radiograph?

A
  • Mass lesion/nodule: carcinoma, TB,abscess, vasculitides
  • Diffuse alveolar infiltrates: Pulmonary oedema
  • Hilar lymphadenopathy: carcinoma, infection, TB
  • Lobar or segmental infiltrates: pneumonia, infarction due to PE, TB
  • Patchy alveolar infiltrates: bleeding disorders, Goodpasture’s
  • lobar collapse: obstructing carcinoma
28
Q

How can you obtain a tissue biopsy from a suspected tumour?

A

CT guided percutaneous fine needle biopsy or on bronchoscopy.

29
Q

Why do we need tissue samples to diagnose cancer?

A

Cancer is ultimately a pathological diagnosis.

30
Q

What other investigations need to be done to assess cancer?

A

You also need to stage a cancer with a CT scan looking for local spread and lymph node involvement and also a BONE SCAN, looking for bone metastases.

31
Q

What are some common symptoms and signs of TB?

A 
Chronic productive cough 
Fevers
Night sweats
Weight loss
Radiograph: apical cavity or calcified nodule
32
Q

Common symptoms and signs of pneumonia

A 
Fever
cough productive of sputum pleuritic chest pain 
dull areas on percussion 
Crackles
Tachycardia
Tachypnoea 
Raised wCC and CRP
33
Q

Common symptoms and signs of bronchiectasis

A 
Clubbing
Recurrent resp infections
Crackles
Wheeze
Chronic cough productive of sputum 
Haemoptysis 
Dyspnoea at rest
chest pain 
malaise 
fever
34
Q

Signs and symptoms of pulmonary embolism

A
  • Sudden onset pleuritic pain
  • Breathlessness
  • Reduced exercise tolerance
  • Smoking
  • Swollen limb
  • Clotting disorder
  • Contraceptive pill
  • HRT
  • Tachycardia (commonest finding in PE)
35
Q

If you perform a chest radiograph on a patient who most likely has malignancy and find nothing, what other tests do you do?

A

CT scan and if this is still inconclusive then try a PET or fibre optic bronchoscopy.

36
Q

If there is severe haemotysis and haemorrhage, what should be done?

A

With the help of a radiologist, the bleeding point should be identified and emboli zed.

37
Q

Which criteria should you refer to once you suspect a PE?

A

Wells criteria

38
Q

What does a Wells criteria greater than or equal to 4 merit?

A

CTPA

39
Q

What test does a Wells score <4 warrant?

A

D-dimer test

40
Q

What are the criteria for the Wells test and what does each one score?

A 
Clinical signs and symptoms of DVT (3)
PE is the most likely diagnosis (3)
Heart rate >100bpm (1.5)
Immobilization >3 days or surgery in last 4 weeks (1.5)
Previously diagnosed DVT or PE (1.5) 
Haemoptysis (1)
Malignancy diagnosed in last month (1)
41
Q

What are coryzal symptoms?

A

Symptoms of a common cold

42
Q

What are some investigation findings consistent with an infection?

A

Raised WCC, Tachycardia and a raised CRP.

43
Q

What are some signs of consolidation?

A

Dullness on percussion, increased vocal resonance, reduced expansion, reduced breath sounds, crackles.

44
Q

Where does the reactivation of TB most commonly affect?

A

The upper lobes. The mycobacterium tuberculosis is a highly aerobic bacterium and the apices are the most oxygenated parts of the lung.

45
Q

what should you do when a patient is diagnosed with TB or suspected TB?

A
  1. Place the patient in isolation
  2. TB is a notifiable disease so you must notify the authorities for contact tracing. They may screen contacts for latent and active TB, and treat as appropriate.
  3. Check for HIV (could be TB secondary to HIV)
  4. Look for signs of spread to other organs (bones, joint, meningeal irritation, abdominal pain)
46
Q

What type of bacteria should microbiology look for in TB?

A

Acid-fast bacilli. Bear in mind that M. tuberculosis is a very slow growing bacterium and it can therefore take many weeks before a positive result is obtained on culture.

47
Q

What stain is used to look for acid-fast bacilli?

A

Ziehl-Nelson or silver stain

48
Q

What is the initial approach for management of TB according to the NICE guidelines?

A

Long term regimen of 4 antibiotics.

49
Q

Rifampacin is one of the antibiotics used, what should you prewarn patients about?

A

Their urine will become a rich orange colou, it can also render the OCP less effective.

50
Q

What is a recurrent cough productive of green sputum and occasional haemoptysis with a CT showing dilated bronchi suggestive of?

A

Bronchiectasis

51
Q

If someone suffers from chronic rhinitis, sinusitis and serous otitis media, what is this suggestive of?

A

That the patient has an inability to clear mucus.

52
Q

What should the combination of haemoptysis and glomerulonephritis alert you to?

A

The possibility of pulmonary-renal syndrome

53
Q

Cardiovascular causes of clubbing

A 
infective endocarditis
congenital cyanotic heart disease 
atrial myxoma
brachial arteriovenous fistula 
axillary artery aneurysm
54
Q

Respiratory causes of clubbing

A

Pulmonary fibrosis
TB
suppurative lung diseases (CF, abscess, empyema, bronchiectasis)
Bronchial cancer or mesothelioma

55
Q

GI causes of clubbing

A 
IBD
Cirrhosis
Malabsorption e.g. coeliacs
liver abscess
liver or bowel cancer
gastric lymphoma
56
Q

Other causes of clubbing

A 
Congenital clubbing
Thyroid acropachy (associate with Grave's)
57
Q

In a pleural effusion, the fluid can be described as a transudate or an exudate. What is the difference between the two?

A

A transudate is defined as having <25g/L of protein. Transudates are low in protein because they are the result of fluid alone squeezing into the pleural space, either due to increased hydrostatic pressure or decreased oncotic pressure in the vasculature.

An exudate is defined as having >35g/L of protein. Exudates are rich in protein because they are the result of cells in the pleural space: either pathogens, inflammatory cells or malignant cells.

58
Q

How are malignant lung cancers classified and what is the frequency of each?

A

1 Non small cell lung cancer (NSCLC, 80%)

2 Small cell lung cancer (SCLC, 20%)

59
Q

How is a non small cell lung cancer further divided?

A

Adenocarcinoma (30-40%)
Squamous (20-30%)
Large cell carcinoma (10%)
Others (5%)

60
Q

How would you manage a NSCLC?

A

If localised, attempt to remove surgically or treat with radiotherapy.
Otherwise, responds poorly to chemotherapy and has a poor prognosis if disseminated.

61
Q

Describe the management of SCLC and its complications

A

Early metastasis thus surgery rarely therapy of choice
Responsive to chemo but early relapse is common
Chemo mainly given for symptoms

62
Q

Which type of metastatic lung cancer is haemoptysis most common in?

A

Squamous cell carcinoma (type of NSCLC). SCC normally affects lung tissue closer to the hilarious region and thus the blood has relatively little distance to travel before being coughed up.

63
Q

Which cancers most commonly metastasise to the lungs?

A

Secondary lung cancers are most commonly the result of metastasis from the following primary cancers:

  1. Colorectal
  2. Breast
  3. Renal
  4. Female genital tract: cervix, ovary

NOTE: metastatic cancers rarely cause haemoptysis as they tend to be deep in the interstitium rather than endobronchial.

64
Q

Some extra pulmonary manifestations of lung cancer

A

Bone metastases –> bone pain
HPOA (hypertrophic pulmonary osteoarthropathy) –> dull, aching swollen wrists
Ectopic ACTH secretion –> cushingoid features, muscle weakness, oedema and skin hyper pigmentation
Hypercalcaemia secondary to bone metastases or PTH related peptide secreting lung cancer –> hypotonia, hyporeflexia, muscle weakness, confusion.

65
Q

What ectopic endocrine secretions are associated with which lung cancers?What symptoms do they cause?

A

Small cell lung carcinomas are derived from endocrine cells in the lung and therefore have the potential to synthesise and secrete hormones: ADH or ACTH.

ADH secretion –> hyponatraemia
ACTH –> Cushing’s

Squamous cell carcinomas cannot produce cholesterol based steroids but they can produce peptides such as PTHrp –> hypercalcaemia.

66
Q

What extra pulmonary sites does TB most commonly effect?

A

Lymph nodes (Cervical or mediastinal)
Bone: osteomyelitis, septic arthritis
Neurological: meningitis, intracranial granulomas
Renal: granuloma

Oxford clinical cases (4 decks)

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