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Haemoptysis can be an extremely scary symptom to patients, however is not that uncommon. Test yourself on this set of questions to review 2 cases of a patient presenting with haemoptysis – good luck!
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Haemoptysis
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Question 1 |
Stem 1 of 5
A 67 year old man, Trevor, presents to A&E having coughed up blood in the night. He has had a productive cough for the past week but has only produced sputum up to this point, but is concerned that he’s suddenly coughing up blood. He says his GP states he has something called “COPD” but does not remember what it means.
What is the most common cause for COPD exacerbations?
Viral infection | |
Aspiration of liquids | |
Idiopathic | |
Bacterial infection | |
Increase in smoking habit |
Question 1 Explanation:
Bacterial pathogens are thought to be responsible for triggering 50-70% of exacerbations, most common being haemophilus influenzae, streptococcus pneumoniae and Moraxella catarrhalis
Question 2 |
Stem 2 of 5
On examination Trevor is showing increased effort to breath, using his accessory muscles to breath in and out. Which of the following muscles in not used in active inspiration?Pectoralis major | |
Serratus anterior | |
Internal intercostal | |
Sternocleidomastoid | |
Scalenes |
Question 2 Explanation:
The key to this question is thinking what the individual muscle groups are doing. Pectoralis major and minor pull the ribs outwards, the serratus anterior and scalenes pull the ribs upwards, and the sternocleidomastoid elevates the sternum. All these actions increase the volume of the thoracic cavity drawing air in.
The internal intercostal however depress the ribs decreasing the volume of the thoracic cavity, so are therefore use in active expiration.
Question 3 |
Stem 3 of 5
If you were to take an ABG sample from Trevor prior to starting any treatment what would you expect to find, considering he has symptoms for a week?CO2 high, HCO3- low | |
CO2 normal, HCO3- low | |
CO2 low, HCO3- high | |
CO2 high, HCO3- high | |
CO2 low, HCO3- normal |
Question 3 Explanation:
In COPD exacerbations patients will retain more CO2 in their blood stream as they are not as able to exhale as much CO2 out of their body as normal. This will increase the acidity of the blood, as the CO2 is converted to carbonic acid. The body can buffer this change in pH using the extracellular bicarbonate buffer system to compensate for this change by producing more HCO3- to compensate for the low pH. However, this buffering system maintained by the kidneys takes a few days to work so would not work immediately. It is therefore important to recognise this has been a week and not a few hours.
Question 4 |
Stem 4 of 5
A CXR is taken. For on a typical patient presenting with COPD, which one of the following features would you not expect to see?Tented diaphragm | |
Hyperinflation | |
Increased retrosternal air space | |
Bronchial wall thickening | |
Lung bullae |
Question 4 Explanation:
B and C are caused by chronic air retention and overinflation of the lungs. D is caused often be recurrent infections and scaring of the bronchi. E related to chronic emphysema. A is not a sign of COPD, with flattened diaphragm being more typical of COPD due to chronic air retention.
Question 5 |
Stem 5 of 5
As part of treatment for exacerbation of COPD Trevor is given a salbutamol nebuliser. What type of drug is salbutamol?Alpha 1 adrenoreceptor agonist | |
Beta 1 adrenoceptor agonist | |
Alpha 2 adrenoceptor antagonist | |
Beta 2 adrenoceptor antagonist | |
Beta 2 adrenoceptor agonist |
Question 6 |
Stem 1 of 5
A 44 year old man, Karl, comes to his GP with his partner Gail who is concerned that he has had a cough that will not go away and is now producing fresh blood tinged sputum. Gail is worried that he might have TB as one of their neighbours has recently been diagnosed.
Considering the patients presentation, what should be the next investigation step taken by the GP?
Chest ultrasound | |
Sputum sample | |
Peak flow assessment | |
Chest MRI | |
2 Week Wait Referral |
Question 7 |
Stem 2 of 5
What sputum stain can be used to identify TB?Vincent’s stain | |
Ziehl-Neelsen stain | |
McFadyean stain | |
Field’s stain | |
Calcofluor stain |
Question 8 |
Stem 3 of 5
If Karl is diagnosed with TB the registered medical practitioners making that diagnosis has a statutory duty to notify their local council or health protection team. Which of the following is not a notifiable disease in the UK?Food poisoning | |
Legionnaires’ disease | |
Malaria | |
HIV | |
Acute meningitis |
Question 9 |
Stem 4 of 5
On examination Karl is short of breath, states he has ongoing moderate chest pain and clothes look loose on him. If the cause of his symptoms were malignant, what would be the most likely cause?Oesophageal adenocarcinoma | |
Lung Adenocarcinoma | |
Bronchiogenic carcinoma | |
Gastric carcinoma | |
Large cell lung carcinoma |
Question 9 Explanation:
Bronchiogenic carcinomas are the most common malignant cause of haemoptysis.
Question 10 |
Stem 5 of 5
Karl is diagnosed with a lung cancer with metastasis found in local lymph nodes. Soon after his diagnosis Karl has recurrent hiccuping. The GP explains this is due to compression of one of his nerves in his chest. What nerve is most likely being affected?Recurrent laryngeal | |
Phrenic nerve | |
Internal intercostal | |
Superior laryngeal nerve | |
Sympathetic trunk |
Question 10 Explanation:
Hiccups are caused by spasms of the diaphragm which is innervated by the phrenic nerve. In patients with lymphadenopathy in the mediastinum this could be compressing or causing irritation to the phrenic nerve, which could result in long term hiccups.
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