Haemoptysis (oxford clin cases) Flashcards
What is haemoptysis?
Coughing up blood
What may haemoptysis be confused with? Explain what each of the other terms mean
Haemetemasis= vomitting blood
Epixstasis= nose bleed (posterior especially)
Bleeding gums
How can you make sure a patient is actually describing haemoptysis and not haemetemasis, epistaxis or bleeding gums?
Ask them what they think the cause of the bleeding is- they might tell you it felt like it started with a drip in the nose
Ask about the colour of the blood- darker will suggest its partially digested blood
Ask about a history of nosebleeds, alcohol use, gastro conditions
How serious of a symptom is haemoptysis?
Very serious- it is a red flag symptom
Why would you be particularly concerned about haemoptysis?
It can be lifethreatening:
It may be the first presentation of a very serious lung condition
It may be serious if there has been large blood loss
What is the most common cause of haemoptysis?
Infection
What must be ruled out when someone presents with haemoptysis?
Lung cancer
What does haemoptysis when someone is coughing up frank blood suggest?
A vascular problem eg a rupture of a blood vessel eg in cancer, TB, bronchiectasis
What does haemoptysis when someone is coughing up blood streaked sputum suggest?
Infection of the lungs, and if there is large volumes of sputum then bronchiectasis
What does haemoptysis when someone is coughing up frothy sputum suggest?
Pulmonary oedema
What pathologies might sudden haemoptysis suggest?
Vascular problems eg blood vessel rupture from a tumor
PE
What pathologies might gradually worsening haemoptysis suggest?
Bronchiectasis
What other symptoms should you ask about in a history if someone presents with haemoptysis and why?
Is there a cough
Is there sputum- lower resp tract infection?
Has there been sudden and unplanned weight loss- suggestive of TB or cancer
Have there been night sweats- signs of TB or cancer
Is there pleuritic chest pain- suggestive of PE
Is there shortness of breath- sudden onset could be PE and gradual could be heart failure
What might haematuria and/or oligouria alongside haemoptysis suggest?
There are a few conditions that can affect both the kidneys and lungs so consider them as differentials eg Goodpastures, systemic lupus
What factors on history, examination and investigations would raise your suspicions of TB?
Foreign travel especially if there is a lack of immunisation and to a high risk area like Asia
Chronic productive cough with green/ yellow coloured sputum
Weight loss, night sweats
Raised CRP and WCC
Pyrexia
Consolidation or pulmonary oedema on chest radiograph
What factors on history, examination and investigations would raise your suspicions of pneumonia?
Chronic productive cough with green/yellow coloured sputum Pleuritic chest pain Raised WCC and CRP Tachycardia Tachypnoea Crackles on auscultation Low oxygen saturation on room air
What factors on history, examination and investigations would raise your suspicions of bronchiectasis?
Chronic productive cough with large volumes of sputum produced Wheeze Dyspnoea at rest History of recurrent respiratory illness Possible clubbing Crackles and wheeze on auscultation
What is the most common finding on examination in someone with a PE?
Tachycardia with a normal ECG
What factors on history, examination and investigations would raise your suspicions of PE?
Sudden onset pleuritic chest pain Breathlessness (worse on exertion) Swollen limb Being immobile for a long time Clotting disorder Recent surgery Lung cancer Normal ECG Lack of cough
What is the first line investigation when you suspect lung cancer?
Chest x ray
If you suspect lung cancer and chest x ray doesn’t show it what should you do?
Send the patient for a CT scan as it will visualise it better
What investigation is done to help rule out a PE?
D dimer
What scan is done if a high risk of PE is suspected?
CTPA
What criteria is used to score someone’s risk of PE?
Well’s score
What are the categories in the Well’s score?
PE being the most likely diagnosis
Clinical signs or symptoms of DVT
Being immobilised for 3 days or surgery in the past 4 weeks
Previous DVT or PE
High heart rate (over 100/min)
Malignancy diagnosed in the last 6 months
What will you see during a resp examination when someone has TB?
Crackles
Reduced chest expansion
Hyperresonance/dull on percussion
Reduced breath sounds on auscultation
What must doctors do if they suspect someone has TB after ABC?
Inform the authorities (TB is a notifiable disease)
Check the infection hasn’t spread to other parts of the body (meninges, spine, organs)
Test for HIV as it could be secondary to HIV
Place the patient in isolation to prevent spread
What is the first line treatment for TB?
A group of 4 abx, 2 for 2 months and 2 for 4 months
What are side effects of treatment of TB?
One abx will turn urine bright orange
It was also make the oral contraceptive pill less effective so alternate methods of contraception should be used
What is the pathophysiology underlying bronchiectasis?
Chronic inflammation of the airway leads to a build up of scar tissue
This tissue shrinks and pulls the airway walls out leading to a widened airway
There is also difficulty clearing mucus due to chronic inflammation damaging the cilia which results in a productive cough
Why is sputum sometimes coloured green?
Due to the presence of neutrophils and macrophages- when they die they release an enzyme which is green in colour
What are the 2 types of fluids in pleural effusion?
Transudate
What is transudate?
Fluid in the pleural cavity that is lower in protein as it has been squeezed out of the lung vasculature
Where does transudate come from?
The lung vasculature
What is exudate?
Fluid in the pleural cavity that is rich in protein and originates from cells in the cavity eg pathogens or malignant cells
Where does exudate originate from?
Cells in the pleural cavity eg pathogens, cancer
What are the types of of lung cancer?
Small cell lung cancer
Non- small cell lung cancer (squamous cell, adeno and large cell carcinoma)
What is the difference between grade and stage?
Stage= how far it has spread Grade= how histologically different it is to normal cells
