Haemoptysis

Question 1

Which score is used to assess for PE.

What do you do with the number

Answer 1

Well’s criteria.

Includes:
Clinical signs and symptoms of DVT-3 points
PE is the most likely diagnosis- 3 points
Heart rate >100 bpm- 1.5 points
Immobilization >3 days or surgery in the last 4 weeks- 1.5 points
Previously diagnosed DVT or PE- 1.5 points
Haemoptysis- 1 point
Malignancy diagnosed in the last 6 months- 1 point

Well’s score of 4 or greater merits a CTPA

Score of less than 4 only justifies d-dimer to exclude PE

Question 2

Which part of the lungs does reactivation of TB often affect and why

Answer 2

Reactivation of TB typically (although not always) aff ects the upper lobes because Mycobacterium tuberculosis is a highly aerobic bacterium and the apices are the most oxygenated part of the lungs.

Question 3

What should you tell micro to look for if you suspect TB

Answer 3

Acid fast bacilli (AFB)

Question 4

What things must you do with TB patient

Answer 4

1. Ensure micro know to look for AFB
2. Notify the autorities for contact tracing
3. Place patient in isolation to prevent further spread
4. Test them for HIV (the TB could be secondary to HIV)
5. Look for signs of spread

Question 5

Where might TB spread to and what symptoms

Answer 5

Meningeal irritation, bone or joint pain in the weight-bearing joints, dysuria and pelvic pain, abdo pain

Question 6

What drugs do you give for TB

Answer 6

For the first 4 months:
Rifampacin, isoniazid, pyrazinamide and ethambutol

Then for the 2 months after just rifampicin and isoniazid

Question 7

What is bronchiectasis- any features?

Answer 7

Dilated airways

• productive of green sputum
• occasional haemoptysis

Question 8

Read the case of Mr Frick!

Answer 8

……

Question 9

What happens in bronchiectasis- why does it cause dilated airways

Answer 9

For some reason, the lung fails to clear irritant mucus.
There is chronic inflammation which leads to scar tissue formation. The scar tissue shrinks after a while, pulling in the wall of the bronchi.

Question 10

Why might someone with bronchiectasis also have chronic sinusitis or lack of fertility

Answer 10

Primary Ciliary Dyskinaesia is when there is a protein lacking called dynein from cilia. It leaves you with an inability to clear mucus.

Autosomal recessive.

Affects the protein machinery used by epithelial cells to rhythmically beat their cilia and by spermatozoa to rhythmically beat their tails.

Question 11

What are the consequences of primary ciliary dyskinaesia

Answer 11

• Bronchiectasis
• Otitis media
• Chronic sinusitis
• Male infertility (women usually fine, as movement of oocyte is dependent on peristalsis of fallopian tube rather than cilia lining these tubes)
• Situs inversus.

Question 12

What is situs inversus and why does it occur in people with primary ciliary dyskinaesia?

Answer 12

The rhythmical beating of cilia is thought to play an important part in setting up the usual pattern of body asymmetry during embryogenesis.

Many patients with PCD have their organs on the ‘other side’ (e.g. dextrocardia).

Question 13

What is kartagener’s syndrome (or kartagener’s triad)

Answer 13

Bronchiectasis, sinusitis and situs inversus

Question 14

How do you investigate PCD

Answer 14

biopsy of the nasal mucosa and examination under a microscope, looking for abnormal beating of the ciliated epithelia. Microscopy of spermatozoa of PCD males often reveals immobile spermatozoa.

Question 15

How would you manage PCD

Answer 15

• Regular physiotherapy, to help clear the lungs of mucus.
• Regular or prophylactic antibiotics, to prevent recurrent chest infections and sinusitis.
• Mucolytics can help clear mucus in the lungs and sinuses more easily in some patients.

Question 16

T/F pcd patients sometimes show an improvement in symptoms as they get older

Answer 16

It is worth knowing that patients with PCD tend to show an improvement of symptoms by their early thirties and that many patients lead near normal adult lives.

Question 17

What are red cell casts in urine

Answer 17

clumps of red cells that have squeezed through the glomeruli

Question 18

What is nephritic syndrome vs nephrotic syndrome

Answer 18

nephrotic syndrome involves the loss of a lot of protein, whereas nephritic syndrome involves the loss of a lot of blood.

Question 19

Outline features of nephrotic syndrome

Answer 19

Proteinuria

Hypoalbuminuria (protein leaving blood into urine through gaps in podocytes)

Oedema (oncotic pressure of blood reduces)

Dyslipidaemia (liver tries to increase albumin production, but increases fat production in the process too)

Question 20

Outline features of nephritic syndrome

Answer 20

Haematuria

Proteinuria too!

HTN (usually only mild)

Low urine volume due to reduced renal function

Question 21

What is likely to be the onset of a lung cancer causing haemoptysis

Answer 21

Actually sudden.

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

Gradual onset points to a progressive condition such as bronchiectasis.

Question 22

Causes of pulmonary renal syndrome

Answer 22

Goodpasture’s syndrome, an autoimmune condition where autoantibodies − attack the lungs and the glomeruli in the kidneys. This is important to identify early since the patient progresses rapidly to irreversible renal failure

Vasculitides, e.g. Wegener’s granulomatosis, microscopic polyangiitis, − polyarteritis nodosa

Systemic lupus erythematosus.

Question 23

Why might wasting of the dorsal interossei worry you

Answer 23

Could indicate invasion of T1 nerve root by apical lung cancer (Pancoast tumour)

Question 24

Why might a swollen face worry you with haemoptysis

Answer 24

Could indicate obstruction of superior vena cava by tumour

Question 25

What is saddle nose representing

Answer 25

Wegeners granulomatosis

Question 26

Why might you spot tracheal deviation with a lung tumour

Answer 26

lung collapse secondary to a large mass such as a tumour or abscess

Question 27

What can cause crackles on auscultation

Answer 27

pneumonia, left ventricular failure, bronchiectasis

Question 28

What might cause pleural rub on ausculatation

Answer 28

?mesothelioma, pleuritis from pneumonia, distal PE causing infarction and associated pleurisy

Question 29

When are the Head/mantoux skin sensitivity tests used in TB

Answer 29

Th e skin sensitivity tests (Heaf, Mantoux) and newer T-cell based assays (e.g. Quantiferon, ELIspot) are only useful to determine latent TB infection and tell you nothing about disease activity.

As many people are infected but not diseased, these tests are of little diagnostic value. Th ey are used in contact tracing to see if somebody who has been exposed to open TB has become infected.