1. Haemoptysis Mudher Al-khairalla

2. Mrs Reddy coughed up blood What would you like to know?

3. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount?

4. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount? Nose? Nose? GI? GI? Vomit? “Coffee Ground” Haematemesis Dark and acidotic Melaena (also swallowed blood) Bronchial Bronchial

5. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount?

6. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount?

7. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount? Frothy Frothy Old Old Rusty Rusty Streaks Streaks Mixed with sputum? Mixed with sputum? If not consider infarction and trauma

8. Haemoptysis Source? Source? Onset? Onset? Duration? Duration? Character? Character? Amount? Amount? Massive Massive ≥ 600 mls in 24h Admission May need emergency treatment Non massive Non massive < 600 mls in 24h Usually Ix as OP

9. What could be causing Mrs Reddy’s haemoptysis?

10. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary

11. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary Wounds Wounds Post intubation Post intubation Foreign Body Foreign Body

12. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary Pneumonia Pneumonia Abscess Abscess Acute Bronchitis Acute Bronchitis Tuberculosis Tuberculosis Bronchiectasis Bronchiectasis Fungi Fungi

13. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary Primary Primary Secondary Secondary Lung Breast Brain Prostate Colon Other

14. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary Pulmonary Embolism Pulmonary Embolism Vasculitis Vasculitis SLE Wegener’s RA Osler-Weber-Rendu Arteriovenous malformation (AVM) Arteriovenous malformation (AVM)

15. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary Interstitial Lung Disease (ILD) Interstitial Lung Disease (ILD) Sarcoid Sarcoid Haemosiderosis Haemosiderosis Goodpasture’s syndrome Goodpasture’s syndrome Cystic Fibrosis Cystic Fibrosis

16. Causes Trauma Trauma Infective Infective Neoplastic Neoplastic Vascular Vascular Parenchymal Parenchymal Non pulmonary Non pulmonary CVS CVS Pulmonary oedema Mitral stenosis Aortic aneurysm Eisenmenger’s Syndrome Bleeding Diathesis Bleeding Diathesis Including Drug induced

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

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

19. What are the possible diagnoses? 1. Tumour 2. TB 3. Pneumonia 4. Mycobateria other than TB (MOTT) 5. Any of them

20. What are the possible diagnoses? 1. Tumour 2. TB 3. Pneumonia 4. Mycobateria other than TB (MOTT) 5. Any of them

21. What would you like to do next? 1. Sputum MC+S 2. Induced sputum x3 for AFB 3. CT Chest 4. Commence Antibiotics 5. Blood Cultures

22. What would you like to do next? 1. Sputum MC+S 2. Induced sputum x3 for AFB 3. CT Chest 4. Commence Antibiotics 5. Blood Cultures

23. Sputum samples are negative for AFB You still have high index of suspicion what next? 1. Bronchial Biopsy 2. Bronchiio-Alveolar Lavage (BAL) 3. CT biopsy 4. Mantoux test 5. Repeat CXR in 2 months

24. Sputum samples are negative for AFB You still have high index of suspicion what next? 1. Bronchial Biopsy 2. Bronchio-Alveolar Lavage (BAL) 3. CT biopsy 4. Mantoux test 5. Repeat CXR in 2 months

25. Peter is 31. He is a non smoker, suffers from heartburn and works in a job centre. He presents with coughing up 3 glass-fulls of fresh blood over 24 hours. He normally keeps well and his mother has had problems with “DVT” in the past.

26. 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

27. You put him on oxygen and start him on… 1. Warfarin 2. Low Molecular Weight Heparin 3. Aspirin 4. Streptokinase 5. Traneximic acid

28. You put him on oxygen and start him on… 1. Warfarin 2. Low Molecular Weight Heparin 3. Aspirin 4. Streptokinase 5. Traneximic acid

29. Which investigation would you arrange? 1. CTPA 2. CT chest 3. HRCT 4. PFTs + DLCO 5. V/Q scan

30. Which investigation would you arrange? 1. CTPA 2. CT chest 3. HRCT 4. PFTs + DLCO 5. V/Q scan

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

32. Which test would you choose? 1. CTPA 2. CT chest 3. HRCT 4. PFTs + DLCO 5. V/Q scan

33. Which test would you choose? 1. CTPA 2. CT chest 3. HRCT 4. PFTs + DLCO 5. V/Q scan

34. 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.

35. He has fine inspiratory crackles at the bases and midzones,raised jugular venous pressure and has a heart rate of 110

36. This is his ECG

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

38. What does this show? 1. Normal sinus rhythm 2. Left Bundle Branch Block (LBBB) 3. Right Bundle Branch Block (RBBB) 4. ST elevation myocardial infarction 5. Ventricular tachycardia

39. What does this show? 1. Normal sinus rhythm 2. Left Bundle Branch Block (LBBB) 3. Right Bundle Branch Block (RBBB) 4. ST elevation myocardial infarction 5. Ventricular tachycardia

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

41. Which of the following is likely to be present on his CXR? 1. Cardiomegaly 2. Upper lobe venous diversion 3. Pleural effusion 4. Kerley B Lines 5. Perhilar patchy opacification (Bat’s wing)

42. Which of the following is likely to be present on his CXR? 1. Cardiomegaly 2. Upper lobe venous diversion 3. Pleural effusion 4. Kerley B Lines 5. Perhilar patchy opacification (Bat’s wing)

43. What has caused his deterioration? 1. Acute Bronchitis 2. Cryptogenic organising pneumonia 3. Pulmonary embolism 4. Acute pulmonary oedema 5. Aspiration pneumonia

44. What has caused his deterioration? 1. Acute Bronchitis 2. Cryptogenic organising pneumonia 3. Pulmonary embolism 4. Acute pulmonary oedema 5. Aspiration pneumonia

45. End!