Core Clinical Problems
Haemoptysis
Mrs Reddy coughed up
blood
What would you like to know?
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?
Nose?
 GI?




Vomit?
“Coffee Ground”
Haematemesis



Dark and acidotic
Melaena (also
swallowed blood)
Bronchial
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?





Frothy
Old
Rusty
Streaks
Mixed with sputum?

If not consider
infarction and trauma
Haemoptysis





Source?
Onset?
Duration?
Character?
Amount?

Massive




≥ 500 mls in 24h
Admission
May need emergency
treatment
Major


200-500 mls in 24h
Non Major <100-200
ml OP Inv
What could be causing Mrs
Reddy’s haemoptysis?
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary
Wounds
 Post intubation
 Foreign Body

Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary






Pneumonia
Abscess
Acute Bronchitis
Tuberculosis
Bronchiectasis
Fungi
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary
Primary
 Secondary







Lung
Breast
Brain
Prostate
Colon
Other
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary
Pulmonary Embolism
 Vasculitis






SLE
Wegener’s
RA
Osler-Weber-Rendu
Arteriovenous
malformation (AVM)
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary





Interstitial Lung
Disease (ILD)
Sarcoid
Haemosiderosis
Goodpasture’s
syndrome
Cystic Fibrosis
Causes






Trauma
Infective
Neoplastic
Vascular
Parenchymal
Non pulmonary

CVS
Pulmonary oedema
 Mitral stenosis
 Aortic aneurysm
 Eisenmenger’s
Syndrome


Bleeding Diathesis

Including Drug
induced
Mrs Reddy is 42.
She presents with
haemoptysis, weight loss of
10 kg over 2 months and
night sweats.
She has never smoked
Her CXR shows cavitation in
the right upper zone.
What are the possible diagnoses?
1.
2.
3.
4.
5.
Tumour
TB
Pneumonia
Mycobateria other
than TB (MOTT)
Any of them
0%
1
0%
2
0%
0%
3
4
0%
5
What would you like to do next?
1.
2.
3.
4.
5.
Sputum MC+S
Induced sputum
x3 for AFB
CT Chest
Commence
Antibiotics
Blood Cultures
0%
1
0%
2
0%
0%
3
4
0%
5
Sputum samples are negative for AFB. You still
have high index of suspicion. What next?
1.
2.
3.
4.
5.
Bronchial Biopsy
Bronchiio-Alveolar
Lavage (BAL)
CT biopsy
Mantoux test
Repeat CXR in 2
months
0%
1
0%
2
0%
0%
3
4
0%
5
Peter is 31.
He is a non smoker , suffers from
heartburn and works in a job centre.
He presents with coughing up a
small cup full of fresh blood over 24
hours.
He normally keeps well and his
mother has had problems with “DVT”
in the past.
His CXR is normal and you
note that his RR is 24/min, HR
96/min and BP 121/63.
His pO2 on room air is 8.3 kPa
You put him on oxygen and start
him on...
1.
2.
3.
4.
5.
Warfarin
Low Molecular
Weight Heparin
Aspirin
Streptokinase
Traneximic acid
0%
1
0%
2
0%
0%
3
4
0%
5
What investigation would you
arrange?
1.
2.
3.
4.
5.
CTPA
CT chest
HRCT
PFTs + DLCO
V/Q scan
0%
1
0%
2
0%
0%
3
4
0%
5
If Peter was 30 years
older,smoked all his life and
had emphysema on his CXR
Which test would you choose?
1.
2.
3.
4.
5.
CTPA
CT chest
HRCT
PFTs + DLCO
V/Q scan
0%
1
0%
2
0%
0%
3
4
0%
5
George is 73. He presents acutely with
breathlessness and coughing up frothy pink
sputum. He has been suffering from
orthopnoea, PND and ankle oedema over
several days.
He has fine inspiratory crackles at the bases
and midzones, raised jugular venous pressure
and has a heart rate of 110
This is his ECG
www.med.umich.edu/lrc/baliga/case01/LBBB.html
What does this show?
1.
2.
3.
4.
5.
Normal sinus rhythm
Left Bundle Branch
Block (LBBB)
Right Bundle Branch
Block (RBBB)
ST elevation myocardial
infarction
Ventricular tachycardia
0%
1
0%
2
0%
0%
3
4
0%
5
!
www.med.umich.edu/lrc/baliga/case01/LBBB.html
Which of the following is likely to
be present on his CXR?
1.
2.
3.
4.
5.
Cardiomegaly
Upper lobe venous
diversion
Pleural effusion
Kerley B Lines
Perhilar patchy
opacification (Bat’s
wing)
0%
1
0%
2
0%
0%
3
4
0%
5
What has caused his
deterioration?
1.
2.
3.
4.
5.
Acute Bronchitis
Cryptogenic organising
pneumonia
Pulmonary embolism
Acute pulmonary
oedema
Aspiration pneumonia
0%
1
0%
2
0%
0%
3
4
0%
5
End!