Haemoptysis Flashcards
In a patient with haemoptysis, what ddx are there
Infective; Pulmonary TB, bronchitis, pneumonia
Neoplastic: primary lung ca, metastatic lung ca
Vascular: PE, LVF, coagulopathy, arteriovenous malformation
Inflammatory: granulomatosis with polyangitis, polyarteritis nodosa, microscopic polyangiitis
Traumatic: iatrogenic, wounds
Degenerative: bronchiectasis
Drugs: warfarin, crack cocaine
What questions should you ask in the HPC in haemoptysis
- What is he coughing up? - frank blood = vascular problem (invasive cancer, bronchiectasis, TB), a ruptured arteriovenous malformation or vascular bronchial fistula. Blood-streaked sputum = lung infection or bronchiectasis if common. Frothy sputum = pulmonary oedema.
- How much coughing up?
- Sudden onset or progressively worse? - sudden onset = ?PE or cancer eroded into blood vessel. Gradual onset = ?bronchiectasis
Name 2 things that pulmonary oedema can be secondary to
LVF or severe mitral stenosis
Haemoptysis that has productive sputum indicates?
LRTI or bronchiectasis
Fever and/or night sweats may indicate?
TB or another LRTI
Haemoptysis with pleuritic chest pain may indicate?
PE or pneumonia
SOB with haemoptysis indicates?
Acute onset = PE
Gradual onset = HF
What rare conditions may haematuria and haemoptysis indicate
- Goodpastures syndrome - autoimmune condition where autoantibodies attack lungs and kidneys
- Vasculitides - e.g. granulomatosis with polyangiitis
- SLE
In the social history what is important to know
- Smoking
2. Asbestos/industrial substance exposure
What aspects of the PMH is it important to know
- Prior lung disease? - indicates chronic condition e.g. TB/bronchiectasis or infection (e.g. pneumonia) vulnerability
- Travel hx
- DVT RFs?
- On any anticoagulants? - can increase magnitude of haemorrhage
On examination of someone with haemoptysis what should you look out for?
General inspection: hoarse voice (cancer invading recurrent laryngeal nerve), cachexia, purpuric rash/petechiae (vasculitis affecting lungs)
Hands: clubbing (lung ca/abscesses, bronchiectasis), wasting of dorsal interossei (apical lung cancer invading T1 nerve root)
Arms: hypotonic/hyporeflexive/weak (hypercalcaemia due to bone metastases from lung cancer)
Face: swollen face (SVC obstruction by tumour), saddle nose (granulomatosis with polyangiitis), Horners syndrome (apical lung cancer invades sympathetic supply to face), jaundice (liver cancer spread to lungs), focal neurology (brain mets)
Neck: cervical lymphadenopathy, non tender (TB, bronchial carcinoma), Virchows node (GI malignancy metastasis to lungs), tracheal deviation (pleural effusion due to cancer? lung collapse secondary to large mass e.g. tumour/abscess)
Chest: asymmetrical lung expansion (lung pathology), dull percussion (malignant pleural effusion, pneumonia, lung abscess), stridor (tumour/FB obstructing bronchus), crackles (pneumonia, LF, bronchiectasis), pleural rub (mesothelioma, pleuritis from pneumonia)
Other: Hepatomegaly (liver malignancy), DVT signs
What investigations would you do for someone with haemoptysis
Oxygen saturation
Bloods: FBC, CRP, clotting screen, U&Es (Goodpastures syndrome and granulomatosis with polyangiitis affects lungs and kidneys), Ca/Phosphate/ALP (bone metastasis from primary lung cancer), liver enzymes for involvement of a cancer, urinalysis, CXR
On a CXR, what signs would you look for?
- Mass/lesion
- Diffuse alveolar infiltrates (pulmonary oedema)
- Hilar lymphadenopathy
- Lobar/segmental infiltrates
- Patchy alveolar infiltrates (bleeding disorders, Goodpastures syndrome, idiopathic haemosiderosis)
- Lobar collapse
Presence of a “coin” lesion near the hilum on a CXR indicates?
Lung cancer/metastasis
A Wells score of less than 4 indicates what?
A wells score of over 4 indicates what?
<4 = D dimer >4 = CTPA
