Haemoptysis

Question 1

What other symptoms may be mistaken for haemoptysis?

Answer 1

• Haematemesis
• Nose-bleed
• Bleeding gums

Question 2

Use the surgical sieve to construct a differential diagnosis for haemoptysis.

Answer 2

• Infection TB Pneumonia (e.g. Klebsiella) Lung abscess Mycetoma Bronchitis - Neoplastic Lung cancer - Vascular PE Left ventricular failure Bleeding diathesis Arteriovenous malformation Vascular-bronchial fistula - Inflammatory/Autoimmune Granulomatosis with polyangiitis Goodpasture’s syndrome SLE Osler-Weber-Rendu syndrome Polyarteritis nodosa - Trauma Iatrogenic - Endocrine - Degenerative Bronchiectasis - Metabolic - Drugs Warfarin Crack cocaine use

Question 3

Which of the mechanisms listed in the surgical sieve is the most common cause of haemoptysis?

Answer 3

Infection

Question 4

What is haemoptysis?

Answer 4

the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs

Question 5

List three key features of the history of presenting complaint.

Answer 5

Describe what you are coughing up. How much was coughed up? Did the haemoptysis occur suddenly or come on gradually?

Question 6

Which differentials are associated with coughing up: Frank blood Blood-streaked sputum Frothy sputum

Answer 6

Frank blood Suggest vascular problem (e.g. erosion of cancer into a blood vessel) Blood-streaked sputum Lung infections can cause this Chronic production of large amounts of blood-stained sputum suggests bronchiectasis Frothy sputum Pulmonary oedema

Question 7

Which disease is classically associated with the production of a large amount of sputum?

Answer 7

Bronchiectasis

Question 8

List some causes of sudden-onset haemoptysis.

Answer 8

PE Erosion of cancer into a blood vessel

Question 9

List a cause of gradual-onset haemoptysis.

Answer 9

Bronchiectasis (and other progressive diseases)

Question 10

List some important symptoms that may be associated with haemoptysis. State the underlying pathology that may cause the symptoms.

Answer 10

Cough productive of sputum – suggests lower respiratory tract infection or bronchiectasis Fever – associated with lower respiratory tract infections Weight loss – systemic feature of lung cancer and TB Pleuritic chest pain – PE or pneumonia Shortness of breath – clarify whether it is sudden-onset (e.g. PE) or gradual-onset (e.g. heart failure) Haematuria/Oliguria

Question 11

Why is it important to ask about renal symptoms (haematuria/oliguria)?

Answer 11

Pulmonary-renal syndromes can cause haemoptysis

Question 12

List the main causes of pulmonary-renal syndrome.

Answer 12

Vasculitides (e.g. Granulomatosis with polyangiitis) SLE Goodpasture’s syndrome

Question 13

List some key features of the past medical history.

Answer 13

Smoking Exposure to asbestos and other inhaled substances Prior lung disease (e.g. TB) Growing up abroad and recent travel Risk factors for DVT/PE Anticoagulant use or bleeding diathesis

Question 14

List some respiratory causes of clubbing.

Answer 14

Lung cancer Bronchiectasis Interstitial lung disease Empyema

Question 15

Which respiratory disease can cause wasting of the dorsal interossei?

Answer 15

Pancoast lung tumours can invade the T1 nerve root

Question 16

Which metabolic imbalance is important to watch out for in patients with potential lung cancer?

Answer 16

Hypercalcaemia of malignancy This is due to spread of the cancer to bone NOTE: keep and eye out for signs of hypercalcaemia (e.g. hypotonia, Hyporeflexia, weak arms)

Question 17

What symptom can occur as a result of obstruction of the superior vena cava by an apical lung tumour?

Answer 17

Swelling of the face, neck and arms

Question 18

List some signs of respiratory pathology that can be seen in the neck.

Answer 18

Cervical lymphadenopathy Tracheal deviation

Question 19

List some blood tests that may be useful in investigating a patient with haemoptysis.

Answer 19

FBC – check for anaemia, raised WCC CRP Clotting screen U&Es – renal derangement may raise suspicion of pulmonary-renal syndrome

Question 20

Why might it be useful to perform urinalysis on a patient presenting with haemoptysis?

Answer 20

Haematuria may increase index of suspicion of pulmonary-renal syndrome

Question 21

What form of imaging is most useful in a patient presenting with haemoptysis?

Answer 21

CXR – look for mass lesions, diffuse alveolar infiltrate, hilar lymphadenopathy etc.

Question 22

Why might it be useful to check calcium, phosphate and ALP in a patient with haemoptysis?

Answer 22

Bone metastases can lead to hypercalcaemia

Question 23

Which criterion is used to decide the next step in the management of a patient presenting with a possible PE?

Answer 23

Wells criteria

Question 24

How is the Wells score interpreted?

Answer 24

4+ = CTPA < 4 = D-dimer to rule out PE

Question 25

Describe the typical presentation of a tuberculosis patient.

Answer 25

History of growing up/recent travel to a TB-endemic region Haemoptysis Night sweats Weight loss

Question 26

Outline the management plan for TB.

Answer 26

4 months: rifampicin + isoniazid 2 month: ethambutol and pyrazinamide

Question 27

Describe the typical presentation of a patient with bronchiectasis.

Answer 27

Recurrent cough productive of large amounts of green/rusty sputum with occasional haemoptysis

Question 28

Which imaging modality is most useful for diagnosing bronchiectasis?

Answer 28

CT chest – shows dilated bronchi

Question 29

What is primary ciliary dyskinesia?

Answer 29

Autosomal recessive disorder that affects the protein machinery used by epithelial cells to beat their cilia

Question 30

What are the consequences of primary ciliary dyskinesia?

Answer 30

NOTE: most consequences are due to the inability of the cilia to clear mucus Bronchiectasis Rhinitis and sinusitis Otitis media Male infertility (sperm are immobile) Situs inversus (Kartagener’s syndrome)