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