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APPROACH TO HEMOPTYSIS
HISTORY AND CLINICAL EXAMINATION.

Nikhil Panjiyar
Roll:13,IIIrd year
Aug 2014th batch

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HEMOPTYSIS
Hemoptysis is the expectoration of blood or bloody sputum from the
lungs or tracheobronchial tree.

Expectoration of 200 ml of blood in a single episode suggests severe bleeding


expectoration of 400 ml in 3 hours or more than 600 ml in 16 hours signals a life-
threatening crisis.

Hemoptysis can range from blood-tinged sputum to life-threatening large volumes of bright
red blood.

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CAUSES 3

Usually results from chronic bronchitis, lung cancer, or


bronchiectasis.
It may also result from inflammatory, infectious, cardiovascular, or
coagulation disorders and, rarely, from a ruptured aortic aneurysm.

The most common causes of massive hemoptysis are lung cancer,


bronchiectasis, active tuberculosis, and cavitary pulmonary disease
from necrotic infections or tuberculosis.

In up to 15% of patients, the cause is unknown.

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HISTORY AND PHYSICAL EXAMINATION.

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HEMOPTYSIS IS FIRST DIFFERENTIATED


FROM OTHER COMMON SOURCE OF
BLEEDING INCLUDING UPPER
RESPIRATORY TRACT AND
GASTROINTESTINAL TRACT.

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HISTORY AND PHYSICAL EXAMINATION

Begins with an assessment of vitals signs and oxygen saturation.

Specific focus on respiratory and cardiac examinations are important.

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INSPECTION

Inspect nares,mouth and pharynx for the source of bleeding.(specific attention is


given as they are the potential source of bleeding.)

Inspect the configuration of chest and look for abnormal movement during
breathing, use of accessory muscles, and retractions.

Observe respiratory rate, depth, and rhythm.

Finally, examine skin for lesions.

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PALPATION

Palpate the patient's chest for diaphragm level and for tenderness, respiratory

excursion, fremitus, and abnormal pulsations.

Also look for masses and lymph nodes.

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PERCUSSION

Flatness Dullness Tympany

Resonance Hyperesonance

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AUSCULTATION

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INVESTIGATIONS
Sputum smear and culture.
Standard chest radiograph (plain x-ray).
Computed tomography.
Bronchoscopy.
Complete blood count.
Coagulation studies.
Pulmonary arteriography.
Lung biopsy.
Renal function and urinanalysis.

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DIFFERENTIAL DIAGNOSIS

Aortic aneurysm (ruptured): Lead to sudden death

Bronchial adenoma: Causes recurrent hemoptysis along with chronic cough and local
wheezing.

Bronchiectasis: Vary from blood-tinged sputum to blood.Typically present with chronic


cough producing copious amount of foul smelling sputum. may also exhibit coarse crackles,
clubbing (a late sign),fever, weight loss, fatigue, weakness, malaise, and dyspnea on exertion.

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Bronchitis (chronic):Typically present with a productive cough that lasts at least 3


months including dyspnea, prolonged expirations, wheezing, scattered rhonchi, accessory
muscle use, barrel chest, tachypnea, and clubbing.

Coagulation Disorders: Thrombocytopenia and Disseminated intravascular


coagulation can cause hemoptysis, multisystem hemorrhage and purpuric lesions.

Laryngeal cancer: Hoarness is usually the initial sign and other finding related are
dysphagia, dyspnea, stridor, cervical lymphadenopathy, and neck pain.

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Lung abscess:Produces blood-streaked sputum resulting from bronchial ulceration,


necrosis, and granulation tissue.

Common associated findings include a cough producing large amounts of


purulent, foul-smelling sputum; fever with chills; diaphoresis; anorexia; weight
loss; headache; weakness; dyspnea; pleuritic or dull chest pain; and clubbing.

Auscultation reveals tubular or cavernous breath sounds and crackles.

Percussion reveals dullness on the affected side.

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Lung cancer:Related findings include a productive cough, dyspnea, fever, anorexia,


weight loss, wheezing, and chest pain.

Plague: Pneumonic form of this acute bacterial infection, caused by Yersinia pestis, can
produce hemoptysis, a productive cough, chest pain, tachypnea, dyspnea, increasing

respiratory distress, and cardiopulmonary insufficiency.

Pulmonary hypertension (primary): Hemoptysis, exertional dyspnea, and fatigue


generally develop late in this disorder.Other findings include arrhythmias, syncope, cough,

and hoarseness.
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Pneumonia: Klebsilla pneumonia- dark brown or red(currant jelly) sputum, begins


abruptly with chills, fever, dyspnea, a productive cough, and severe pleuritic chest pain
associated with cyanosis,prostration,tachycardia,decreased breath sounds & crackles.

Pneumococcal pneumonia-pinkish or mucoid rusty sputum, It begins with


sudden shaking chills; a rapidly rising temperature; and, in over 80% of patients,
tachycardia and tachypnea with severe stabbing chest pain.

Pulmonary arteriovenous fistula: Occurs in young adults with red ruby patches in
face,tongue,skin,mucous membrane and lips.

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Pulmonary tuberculosis:Chronic productive cough, fine crackles after coughing,


dyspnea, dullness on percussion, increased tactile fremitus and,possibly, amphoric breath
sounds.

The patient may also develop night sweats, malaise,fatigue, fever, anorexia, weight
loss, and pleuritic chest pain.

Tracheal trauma:Torn tracheal mucosa may cause hemoptysis, hoarseness,dysphagia,


neck pain, airway occlusion, and respiratory distress.

Silicosis: This chronic disorder causes a productive cough with mucopurulent sputum
that later becomes blood streaked.
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OTHER CAUSES

Pulmonary embolism with infarction

Pulmonary edema

Systemic lupus erythomatosus

Wegeners granulomatosis

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PEDIATRIC POINTERS

May stem from Goodpasture's syndrome, cystic fibrosis, or (rarely) idiopathic


primary pulmonary hemosiderosis.

No cause can be found for pulmonary hemorrhage occurring within the first 2
weeks of life

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GERIATRIC POINTERS
Anticoagulants may be the reason for bleeding.

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TRUE HEMOPTYSIS SPURIOUS(FALSE)HEMOPTYSIS

Below vocal cords. Above vocal cords.

Persist as blood tinged sputum. Doesnt persist.

May be mixed with sputum. Not mixed with sputum.

History of cardiopulmonary disease. Obvious by ENT examination.

CXR may be abnormal. Normal CXR.

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FACTITIOUS HEMOPTYSIS

If no etiology is discernible after a thorough evaluation,especially when the medical

history of the patients behavior is unusual

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