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Probability diagnosis

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Acute chest infection:

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  • URTI (24%)

  • bronchitis

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Chronic bronchitis

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Trauma: chest contusion, prolonged coughing

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Cause often unknown (22%)

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Serious disorders not to be missed

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Vascular:

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  • pulmonary infarction/embolus

  • LHF / pulmonary oedema

  • mitral stenosis

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Infection:

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  • lobar pneumonia (rusty sputum)

  • tuberculosis

  • lung abscess

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Cancer/tumour (4%):

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  • bronchogenic carcinoma

  • tumour of the larynx or trachea

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Other:

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  • blood disorders including anticoagulants

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Pitfalls (often missed)

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Foreign body

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Bronchiectasis (13%)

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Iatrogenic (e.g. endotracheal intubation)

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Spurious haemoptysis (blood from nose or throat)

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Rarities:

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  • idiopathic pulmonary haemosiderosis

  • pulmonary AV malformation

  • Goodpasture syndrome

  • connective tissue disorder

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Key history

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Presenting symptom clarification—is it haemoptysis, haematemesis or bleeding from the nose or throat? General symptoms (e.g. weight loss, fever, pain, esp. pleuritic pain). Respiratory and cardiac history including past history and exposure to TB (e.g. refugees). Drug history especially smoking, alcohol, anticoagulation.

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Key examination

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  • General appearance and vital signs

  • Full respiratory and cardiovascular examination including upper airways and mouth

  • Check legs for evidence of deep venous thrombosis

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Key investigations

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  • Chest X-ray

  • FBE

  • ESR/CRP

  • Sputum M&C

  • Other tests (e.g. CT, bronchoscopy, ECG, echocardiogram, ventilation/perfusion scan) according to clinical findings

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Diagnostic tips

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  • Blood originating from any area can be aspirated throughout lung.

  • Bright red haemoptysis in a young person may be the initial symptom of pulmonary TB.

  • Large haemoptyses are usually due to bronchiectasis or TB.

  • The commonest causes of haemoptysis are URTI (24%), acute or chronic bronchitis (17%), bronchiectasis (13%), TB (10%). Unknown causes total about 22%.

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