Core Clinical Problems Haemoptysis. Mrs Reddy coughed up blood What would you like to know?

Core Clinical ProblemsCore Clinical Problems

HaemoptysisHaemoptysis

Mrs Reddy coughed up Mrs Reddy coughed up bloodblood

What would you like to know?What would you like to know?


Source?Source? Onset?Onset? Duration?Duration? Character?Character? Amount?Amount?



Nose?Nose? GI?GI?

Vomit?Vomit? ““Coffee Ground”Coffee Ground” HaematemesisHaematemesis

Dark and acidoticDark and acidoticMelaena (also Melaena (also

swallowed blood)swallowed blood)

BronchialBronchial



FrothyFrothy OldOld RustyRusty StreaksStreaks Mixed with Mixed with

sputum?sputum? If not consider If not consider

infarction and infarction and traumatrauma



MassiveMassive ≥ ≥ 500 mls in 24h500 mls in 24h AdmissionAdmission May need May need

emergency emergency treatmenttreatment

MajorMajor 200-500 mls in 24h200-500 mls in 24h Non Major <100-Non Major <100-

200 ml OP Inv200 ml OP Inv

What could be causing What could be causing Mrs Reddy’s Mrs Reddy’s

haemoptysis?haemoptysis?

CausesCauses

TraumaTrauma InfectiveInfective NeoplasticNeoplastic VascularVascular ParenchymalParenchymal Non pulmonaryNon pulmonary

CausesCauses


WoundsWounds Post intubationPost intubation Foreign BodyForeign Body

CausesCauses


PneumoniaPneumonia AbscessAbscess Acute BronchitisAcute Bronchitis TuberculosisTuberculosis BronchiectasisBronchiectasis FungiFungi

CausesCauses


PrimaryPrimary SecondarySecondary

LungLung BreastBreast BrainBrain ProstateProstate ColonColon OtherOther

CausesCauses


Pulmonary Pulmonary Embolism Embolism

VasculitisVasculitis SLESLE Wegener’sWegener’s RARA Osler-Weber-RenduOsler-Weber-Rendu

Arteriovenous Arteriovenous malformation malformation (AVM)(AVM)

CausesCauses


Interstitial Lung Interstitial Lung Disease (ILD)Disease (ILD)

SarcoidSarcoid HaemosiderosisHaemosiderosis Goodpasture’s Goodpasture’s

syndromesyndrome Cystic FibrosisCystic Fibrosis

CausesCauses


CVSCVS Pulmonary oedemaPulmonary oedema Mitral stenosisMitral stenosis Aortic aneurysmAortic aneurysm Eisenmenger’s Eisenmenger’s

SyndromeSyndrome Bleeding DiathesisBleeding Diathesis

Including Drug Including Drug inducedinduced

Mrs Reddy is 42. Mrs Reddy is 42. She presents with She presents with haemoptysis, weight loss haemoptysis, weight loss of 10 kg over 2 months of 10 kg over 2 months and night sweats.and night sweats.She has never smokedShe has never smoked

Her CXR shows Her CXR shows cavitation in the right cavitation in the right upper zone.upper zone.

What are the possible What are the possible diagnoses?diagnoses?

1 2 3 4 5

0% 0% 0%0%0%

1.1. TumourTumour

2.2. TBTB

3.3. PneumoniaPneumonia

4.4. Mycobateria Mycobateria other than TB other than TB (MOTT)(MOTT)

5.5. Any of themAny of them

What would you like to do What would you like to do next?next?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Sputum MC+SSputum MC+S

2.2. Induced sputum Induced sputum x3 for AFBx3 for AFB

3.3. CT ChestCT Chest

4.4. Commence Commence AntibioticsAntibiotics

5.5. Blood CulturesBlood Cultures

Sputum samples are negative for AFB. You Sputum samples are negative for AFB. You still have high index of suspicion. What still have high index of suspicion. What

next?next?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Bronchial Bronchial BiopsyBiopsy

2.2. Bronchiio-Bronchiio-Alveolar Lavage Alveolar Lavage (BAL)(BAL)

3.3. CT biopsyCT biopsy

4.4. Mantoux testMantoux test

5.5. Repeat CXR in 2 Repeat CXR in 2 monthsmonths

Peter is 31.Peter is 31.He is a non smoker , suffers from He is a non smoker , suffers from

heartburn and works in a job heartburn and works in a job centre.centre.

He presents with coughing up a He presents with coughing up a small cup full of fresh blood over small cup full of fresh blood over

24 hours.24 hours.He normally keeps well and his He normally keeps well and his mother has had problems with mother has had problems with

“DVT” in the past.“DVT” in the past.

His CXR is normal and you His CXR is normal and you note that his RR is 24/min, note that his RR is 24/min, HR 96/min and BP 121/63.HR 96/min and BP 121/63.His pOHis pO22 on room air is 8.3 on room air is 8.3

kPa kPa

You put him on oxygen and You put him on oxygen and start him on...start him on...

1 2 3 4 5

0% 0% 0%0%0%

1.1. WarfarinWarfarin

2.2. Low Molecular Low Molecular Weight HeparinWeight Heparin

3.3. AspirinAspirin

4.4. StreptokinaseStreptokinase

5.5. Traneximic acidTraneximic acid

What investigation would you What investigation would you arrange?arrange?

1 2 3 4 5

0% 0% 0%0%0%

1.1. CTPACTPA

2.2. CT chestCT chest

3.3. HRCTHRCT

4.4. PFTs + DLCOPFTs + DLCO

5.5. V/Q scanV/Q scan

If Peter was 30 years If Peter was 30 years older,smoked all his life older,smoked all his life and had emphysema on and had emphysema on

his CXRhis CXR

Which test would you Which test would you choose?choose?

1 2 3 4 5

0% 0% 0%0%0%

1.1. CTPACTPA

2.2. CT chestCT chest

3.3. HRCTHRCT

4.4. PFTs + DLCOPFTs + DLCO

5.5. V/Q scanV/Q scan

George is 73. He presents acutely with George is 73. He presents acutely with breathlessness and coughing up frothy breathlessness and coughing up frothy

pink sputum. He has been suffering from pink sputum. He has been suffering from orthopnoea, PND and ankle oedema over orthopnoea, PND and ankle oedema over

several days.several days.

He has fine inspiratory crackles at the He has fine inspiratory crackles at the bases and midzones, raised jugular bases and midzones, raised jugular

venous pressure and has a heart rate of venous pressure and has a heart rate of 110110

This is his ECGThis is his ECG

www.med.umich.edu/lrc/baliga/case01/LBBB.html

What does this show?What does this show?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Normal sinus rhythmNormal sinus rhythm

2.2. Left Bundle Branch Left Bundle Branch Block (LBBB)Block (LBBB)

3.3. Right Bundle Branch Right Bundle Branch Block (RBBB)Block (RBBB)

4.4. ST elevation ST elevation myocardial infarctionmyocardial infarction

5.5. Ventricular Ventricular tachycardiatachycardia

www.med.umich.edu/lrc/baliga/case01/LBBB.html

!

Which of the following is Which of the following is likely to be present on his likely to be present on his

CXR?CXR?

1 2 3 4 5

0% 0% 0%0%0%

1.1. CardiomegalyCardiomegaly

2.2. Upper lobe Upper lobe venous diversionvenous diversion

3.3. Pleural effusionPleural effusion

4.4. Kerley B LinesKerley B Lines

5.5. Perhilar patchy Perhilar patchy opacification opacification (Bat’s wing)(Bat’s wing)

What has caused his What has caused his deterioration?deterioration?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Acute BronchitisAcute Bronchitis

2.2. Cryptogenic Cryptogenic organising organising pneumoniapneumonia

3.3. Pulmonary embolismPulmonary embolism

4.4. Acute pulmonary Acute pulmonary oedemaoedema

5.5. Aspiration Aspiration pneumoniapneumonia

End!End!

Core Clinical Problems Haemoptysis. Mrs Reddy coughed up blood What would you like to know?

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