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Y3 Oxford Cases > Haemoptysis > Flashcards

Haemoptysis Flashcards

1
Q

What may haemoptysis be confused with

A

Haematemesis
Epistaxis
Gum bleeding

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2
Q

How can you help the patient to distinguish haemoptysis from other symptoms

A

Where do they think the blood is coming from
What is the colour of the blood coming out
History of nausea, vomiting, gastric disease or alcoholism

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3
Q

How do you assess for alcoholism

A

CAGE
Cut down - have you tried to cut down, do you want to cut down
Annoyance - do you get annoyed when people ask
Guilty - do you feel guilty about the amount you drink
Eye-opener - is alcohol an eye opener in the morning
A positive response to each questions scores 1 point

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4
Q

Why is haemoptysis an important symptom to investigate

A

May be the presenting symptom for life-threatening lung disease
Massive haemoptysis (>100mL to >1000mL over 24 hours) can lead to asphyxiation or shock
Red flag

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5
Q

What diagnoses should you be concerned about in haemoptysis

A

INVITED MD
Infective - TB, bronchitis, pneumonia, abscess, mycetoma
Neoplastic - primary or metastatic lung cancer
Vascular - PE, LHF, bleeding diathesis
Inflammatory - granulomatosis with polyangiitis , SLE, Goodpasture’s
Traumatic - iatrogenic, wounds
Degenerative - bronchiectasis
Drugs - warfarin, crack cocaine

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6
Q

What questions should be asked about a patient presenting with haemoptysis

A

What is being coughed up? (frank blood, bloody streaks, frothy)
How much is being coughed up
How suddenly did it start, has it gotten worse progressively?

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7
Q

What does the kind of blood being coughed up suggest

A

Frank -vascular problems e.g. erosion of blood vessel (invasive cancer, bronchiectasis, TB, rupture arteriovenous malformation, vascular-bronchial fistula
Streaks - Infections, TB, bronchiectasis
Frothy - Pulmonary oedema due to Left heart failure, Left ventricular failure

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8
Q

What does the onset of haemoptysis signify

A

Sudden onset - PE or erosion of cancer into pulmonary vessel

Gradual onset - progressive e.g. bronchiectasis

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9
Q

What associated symptoms should be asked about for haemoptysis and what is each indicative of

A 
Sputum production - LRTI (pneumonia, bronchitis, TB), bronchiectasis
Fever - LRTI
Night sweats - TB
Weight loss - Lung cancer and TB 
Pleuritic chest pain - PE or pneumonia
SOB - PE or HF (depends on onset)
Haematuria - rare conditions
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10
Q

What does haematuria in the presence of haemoptysis suggest

A

Rare conditions that affect the lung and kidneys - pulmonary-renal syndromes
Goodpasture’s syndrome
Vasculitides e.g. granulomatosis with polyangiitis, polyarteritis nodosa
SLE

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11
Q

What should be asked about social history for haemoptysis

A

Smoking history
Exposure to asbestos or other inhaled industrial substances e.g. silica, coal, radon, arsenic
Grow up or travel abroad - has he been vaccinated for TB
Risk factors for DVT

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12
Q

What signs should be looked for at the end of the bed for haemoptysis

A

Hoarse voice- invasion of recurrent laryngeal nerve by cancer
Cachexia
Purpuric rash or petechiae - vasculitis affecting lungs

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13
Q

What signs should be looked for in the hands for haemoptysis

A

Clubbing - lung cancer, abscess, bronchiectasis
Tar staining
Wasting of the dorsal interossei - invasion of T1 nerve root by Pancoast’s tumour

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14
Q

What signs should be looked for in the arms for haemoptysis

A

Hypotonic, hyporeflexic, weak arms are suggestive of hypercalcaemia due to bone metastases from lung cancer

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15
Q

What signs should be looked for in the face for haemoptysis

A

Swollen face - obstruction of SVC by tumour
Bleeding from oral or nasal mucosa - may not be true haemoptysis
Saddle nose - granulomatosis with polyangiitis
Horner’s - Pancoast’s tumour
Jaundice - liver cancer mets
Focal neurology - brain mets from lung

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16
Q

What signs should be looked in the neck for haemoptysis

A

Cervical lymphadenopathy - TB, bronchial carcinoma
Left supraclavicular lymphadenopathy (Virchow’s node) - GI mets
Tracheal deviation - pleural effusion secondary to cancer

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17
Q

What signs should be looked for in the chest for haemoptysis

A

Asymmetrical lung expansion
Dullness to percussion - pneumonia, abscess, malignant, pleural effusion
Stridor - tumour or foreign body obstructing bronchus
Crackles - pneumonia, LHF, bronchiectasis
Pleural rub - mesothelioma, pleuritis for pneumonia

18
Q

What signs should be looked for in the abdomen and legs for haemoptysis

A

Hepatomegaly - malignancy

Unilateral signs of DVT - PE

19
Q

Which investigations should be ordered for haemoptysis presentaiton

A

Sats + obs
FBC - anaemia due to malignancy, WCC for infection
CRP - infection, inflammation and malignancy
Clotting - bleeding disorder that leads to haemoptysis
U&Es - renak involvement
Calcium, phosphate, Alk phos - bone mets
Liver enzymes - liver involvement of a cancer
Urinalysis - haematuria, sign of renal involvement
CXR

20
Q

What signs would you look for on CXR for haemoptysis

A

Mass lesion/nodules - carcinoma, TB, abscess, vasculitides
Diffuse alveolar infiltrates - pulmonary oedema
Hilar lymphadenopathy - carcinoma, infection, TB
Lobar or semental infiltrates - pneumonia, infarction due to PE, TB, adenocarcinoma
Patchy alveolar infiltrates - bleeding disorders, Goodpasture’s
Lobar collapse - obstructing carcinoma

21
Q

What investigations should be done to confirm lung cancer

A

Cytology of sputum and bronchoscope washings
Tissue biopsy (CT-guided percutaneous fine needle biopsy or bronchoscopy)
CT scan - staging
Bone scan - look for bone mets

22
Q

What scoring system can be used for DVT/PE suspicion

A

Wells criteria
>4 merits CTPA to investigate
<4 - D-dimer for exclusion

Geneva score as alternative

23
Q

What is the management plan for someone with suspected TB

A
  1. ABCDE
  2. Ensure microbiology know to test for acid-fast bacilli i.e. with Ziehl-Nielson
  3. Notify the authorities for contact tracing
  4. Place patient in isolation
  5. Test for HIV
  6. Look for signs of spread to other organs e.g. meningeal irritation, bone or joint pain particularly in weight-bearing joints, dysuria or pelvic pain, abdo pain
  7. Refer to TB service if dianogsis confirmed
24
Q

What is the treatment for TB

A

Depends on likelihood of drug-resistant strains

Long-term regimen of 4 antibiotics: rifampicin and isoniazid, pyrazinamide and ethambutol

25
Q

What should patients starting rifampicin be warned about

A

Will cause orange urine

Will make oral contraceptiv pills less effective

26
Q

What are the consequences of primary ciliary dyskinesia

A 
Bronchiectasis
Rhinitis and sinusistis 
Otitis media 
Male infertility 
Situs inversus
27
Q

What is Kartagener’s triad

A

Bronchiectasis, sinusitis, situs inversus

28
Q

What is the management of primary ciliary dyskinesia

A

Regular physiotherapy
Regular or prophylactic antibiotics
Mucolytics

29
Q

What are the respiratory causes of clubbing

A

Pulmonary fibrosis
Suppurative lung disease: abscess, empyemna, cystic fibrosis, Bronchiectasis
Bronchial carcinoma, mesothelioma
TB

30
Q

What is the difference between transudate and exudate

A

Transudate - <25 g/L protein as they are due to fluid squeezing into the pleural space

Exudate >35 g/L protein

31
Q

What are the cause of transudate pleural effuision

A

Increased hydrostatic pressure in lung vasculature (HF, fluid overload, constrictive pericarditis)
Reduced oncotic pressure (reduced serum protein due to liver failure, malabsorption, nephrotic syndrome)

32
Q

What are the causes of exudate pleural effusion

A

Due to cells in the pleural space, either pathogens (infection), inflammatory cells or malignant cells

33
Q

What is Lights criteria

A

Protein in pleural fluid effusion is 25-35 g/L

Is exudate if:
Protein / serum protein >0.5
Lactate dehydrogenase (LDH) / serum LDH < 0.6
LDH > 2/3 upper limit normal serum LDH

34
Q

How are lung neoplasms classified

A

Benign
Malignant: primary and secondary
Primary: Non small cell lung cancer, small cell lung cancer

35
Q

What can non small cell lung cancer be divided into and what is treatment

A

Adenocarcinoma, squamous, large cell carcinoma + others
Squamous - most likely haemoptysis (hilar location)
Localised - surgery and radiotherapy
Responds poorly to chemo, poor prognosis

36
Q

What is the treatment for small cell lung cancer

A

responsive to chemo, although rapid relapse is common

Given mainly as it improves symptoms rather than mortality

37
Q

Which cancers most commonly metastasise to the lungs

A

Colorectal
Breast
Renal
Cervix and ovary

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

38
Q

What are the extrapulmonary manifestations of lung cancer

A

Bone mets -> bone pain
Hypertrophic pulmonary osteoarthropathy -> dull, aching, swollen wrists/ankles
Ectopic ACTH secretion -> Cushingoid, facial weakness, oedema, skin hyperpigmentation
Hypercalcaemia -> secondary to bone mets, PTH-related peptide-secreting cancer -> confusion, polyuria, polydipsia, hypotonia and reflexia muscle weakness
Eaton-Lambert syndrome (small cell lung cancer)

39
Q

What ectopic endocrine secretions are associated with lung cancers

A

Small cell lung carcinomas - ADH -> hyponatraemia
ACTH -> Cushing’s

Squamous cell carcinoma - PTHrP -> hypercalcaemia

40
Q

What extrapulmonary site does TB commonly affect

A

Lymph nodes: (cervical or mediastinal)
Bone: osteomyelitis, septic arthritis, Pott’s
Neurological: meningitis, intracranial granuloma
Renal: granuloma

41
Q

What are the differentials for a solitary coin lesion on CXR

A 
Parenchymal lung tumour 
Lymphoma
Granuloma (TB, sarcoidosis)
Abscess
Hamartoma
Foreign object

Y3 Oxford Cases (29 decks)

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