Timing Questions:
since when, sudden/gradual, getting worse, how often, new or previous episodes, when was the first time it occurred?
Confirm if patient definitely means coughing blood rather than vomiting.
Ask about black stool (melaena) in case it is actually vomiting blood.
Character:
colour, consistency, quantity (streaks/teaspoon/egg cup/soaking how many tissues), mixed with sputum or not. What is the sputum like?
Any bleeding from elsewhere? Eg. urine, stool, nose, gums
CVS and Resp Systems review questions:
CP (+pleuritic)
SOB, orthopnoea, PND, exercise tolerance, syncope, presyncope, ankle swelling, palps
Cough, sputum (colour, amount, smell etc). Do you produce sputum without haemoptysis?
Wheeze
Fever/chills/night sweats
Leg swelling
Cardiac Risk factors: cholesterol, hypertension, diabetes, smoking, family history
PMH cardiac: MI, TIA/stroke, PVD. Ever had exercise tolerance test/angiogram/ecg etc? Known heart problems?
Fx cardiac problems
PE/DVT risk factors: surgery, pregnant, fractures, cancer, bedbound/recent illness limiting mobility, PMH DVT/PE, Fx DVT/PE, contraceptive pill/HRT, long flights, Fx/PMH clotting problem
PMH respiratory problems eg. COPD
Fx resp problems
TB questions: fever/sweats/weight loss/anorexia/lumps and bumps, TB contacts, travel, country of origin, PMH TB or HIV/ Fx TB
Skin rash/joint symptoms/eye symptoms/blood in urine/epistaxis (vasculitis/lupus)
Weight loss (how much over how long)/headache/bone pain/smoking history/changing cough (lung cancer)
PMH: lung/cardiac/kidneys/thoracic procedure or surgery/bleeding disorder, cancer
Dx: aspirin, NSAIDs, antiplatelets drugs, anticoagulants
Fx: blood clots, haemoptysis/brain aneurysms/epistaxis/GI bleeding (Osler Weber rendu), lung problems
Sx: smoking, alcohol, cocaine+IV drug use, travel history, sexual history, occupational exposure to chemicals/asbestos
Systems Review
ICE
Causes of haemoptysis
Neoplastic:
Lung cancer/mets/carcinoid/ HIV with kaposis sarcoma of the airways
Infective:
Bronchitis
Bronchiectasis including cystic fibrosis
Infective exacerbation of COPD
Lung abscess
TB
Pneumonia eg. Bacterial, viral, fungal and mycetoma, necrotising, parasitic eg. paragonimus westermani, aspergilloma.
Hydatid cysts
UTRI abnormalities eg. Polyps
Cardiac:
Heart failure, tricuspid endocarditis, valve disorder eg. mitral stenosis, congenital heart disease
Vascular:
PE
Pulmonary AVM eg. Osler weber rendu syndrome
Bronchovascular fistula eg. aortic aneurysm eroding into airway
Inflammatory/rheumatic:
Goodpastures disease
Granulomatosis with polyangitis (Wegeners) and other vasculitides eg. polyarteritis nodosa
Lupus or antiphospholipid syndrome
Ehlers danlos
Behcet’s disease
Disorders of coagulation:
Anticoagulant/antiplatelet drugs
ITP, TTP, HUS, DIC, von willebrand disease
Miscellaneous:
Iatrogenic eg. aortobronchial fistula due to stent/graft, bronchoscopy
Drugs and toxins- cocaine
Trauma
Catamenial hemoptysis (intrathoracic endometriosis)
Foreign bodies
Idiopathic pulmonary hemosiderosis
Dieulafoy disease
Cryptogenic haemoptysis
Investigations depending on most likely cause
FBC, U+E, CRP, clotting, Calcium
Urine dip
CXR
Spiro
Blood cultures, HIV test
Sputum culture+ AFBs
Serologic tests for fungal infection eg. Histoplasma Ag, cryptococcal Ag, beta-D-glucan
ANA, ANCA, antiGBM, anticardiolipin, antiphospholipid antibodies, ESR
CT/HRCT/CTangio
Bronchoscopy+ samples for histology, cytology, microbiology
BAL
BNP,ECG, echo
D dimer, CTPA
Biopsy- kidney/skin/lung (transthoracic needle aspiration or VATS/thoracotomy)
Written by Dr Sarah Kennedy
Resources used to write this document include those listed in the references section of this webpage and also:
https://www.uptodate.com/contents/etiology-and-evaluation-of-hemoptysis-in-adults?source=search_result&search=hemoptysis&selectedTitle=1~150#H296832427