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Haemoptysis: History Taking and Differential Diagnoses

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History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Haemoptysis

  • Onset
  • Duration
  • Blood characteristics:
    • How much?
    • Appearance:
      • Streaks?
      • Fresh red blood?
      • Dark clots?
      • Ground-up coffee?
    • Definitely from the airway and not the mouth or nose?
  • Exacerbating factors:
    • Exposure to dust or smoke?
  • Associated symptoms:
    • Cardiovascular and respiratory systems review
    • Chest pain?
  • Have they had any recent illnesses?

Review of systems

  • Screen for malignancy:
    • Fever, weight loss, night sweats?
    • Hoarse voice, throat pain?
    • Any bone pain (may suggest metastases)
  • Screen for additional cardiorespiratory symptoms:
  • Screen for risk factors of pulmonary embolism/deep vein thrombosis:
    • Any calf pain, recent travel, recent surgery, oral contraceptive pill use, pregnancy, malignancy, or family history of clotting problems?
  • Screen for haematological disorders:
  • Screen for risk factors for infection:
    • Any foreign travel?
    • Has anyone around them been ill?

Past Medical History

Questions include:

  • Do they have any other medical conditions?
    • Including lung disease, heart disease, blood disorders, cancer, and autoimmune disorders 
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
    • Were they ever exposed to asbestos or silica?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

Some examination findings include:

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
    • Full blood count (FBC):
      • May identify infection, anaemia, or haematological disorders
    • Clotting screen:
      • May identify clotting disorder
    • Group and save:
      • If blood transfusion is needed
    • D-dimer:
      • For deep vein thrombosis or pulmonary embolism
    • Urea and electrolytes:
      • May show kidney dysfunction such as vasculitis
    • Anti-neutrophilic cytoplasmic antibody (ANCA):
      • For vasculitis
    • Anti-glomerular basement membrane (anti-GBM) antibody:
  • Orifice tests:
    • Urinalysis:
      • For renal dysfunction
    • Sputum cytology and microscopy, culture, and sensitivity:
      • If infection suspected
  • X-rays:
    • Chest x-ray:
      • May identify mass
  • ECGs:
    • ECG:
      • If cardiac cause is suspected 
  • Special tests:
    • Bronchoscopy:
      • If chest imaging does not identify a clear cause
      • May identify bronchogenic carcinoma
    • Transbronchial biopsy:
      • May be taken for histological diagnosis
    • CT pulmonary angiogram or V/Q scan:
      • For pulmonary embolism
    • Echocardiogram:
      • For cardiac causes

Differential Diagnoses

Lung cancer
  • A history may reveal:
    • Cough, haemoptysis, unexplained weight loss, hoarseness, chest pain
    • Features of paraneoplastic syndromes
  • A physical exam may reveal:
    • Focal wheezing, dullness, decreased breath sounds
  • Investigations may reveal:
    • Chest x-ray:
      • Mass present
    • CT chest:
      • Mass present
    • Biopsy:
      • Histologically confirms lung cancer
Bronchiectasis
  • A history may reveal:
    • Chronic cough productive of foul, offensive, copious amounts of sputum
    • Haemoptysis
    • Shortness of breath
    • Recurrent infection
    • Severe infection in childhood
  • A physical exam may reveal:
    • Crackles, wheezing, clubbing
  • Investigations may reveal:
    • Chest x-ray:
      • Thickened airways
    • High-resolution CT chest:
      • Tram-tracking and bronchial dilation
Pulmonary tuberculosis (TB)
  • A history may reveal:
    • Cough, fever, weight loss, night sweats, haemoptysis
    • HIV/immunosuppression
    • Travel to an endemic area
  • A physical exam may reveal:
    • Fever, tachypnoea
  • Investigations may reveal:
    • Chest x-ray:
      • May show bilateral hilar lymphadenopathy, may show upper lobe cavitation
    • Sputum culture:
      • Diagnostic
Pulmonary embolism
  • A history may reveal:
    • Sudden onset shortness of breath
    • Pleuritic chest pain may be present
    • Haemoptysis may be present
    • There may be a history of risk factors such as prothrombic state (e.g. pregnancy, inadequate coagulation, malignancy), prolonged immobilisation (e.g. long-haul flights), recent surgery, or oral oestrogens (e.g. combined oral contraceptive pill or combined oral hormone replacement therapy)
  • A physical exam may reveal:
    • Tachycardia, tachypnoea
    • Crackles and fever may be seen
  • Investigations may reveal:
    • Chest x-ray – done to screen for other pathologies such as pneumothorax
      • Usually clear
      • May show wedge-shaped opacification
    • ECG:
      • Sinus tachycardia is the most common feature
    • D-dimer:
      • Elevated
    • CT angiography or V/Q scan:
      • Diagnostic
Lung abscess
  • A history may reveal:
    • High fever (>38.5°C), productive cough with foul-smelling sputum, chest pain, shortness of breath
    • Risk factors such as aspiration pneumonia, poor dental hygiene, infective endocarditis, chronic alcohol excess
  • A physical exam may reveal:
    • High fever, dull percussion and bronchial breathing, decreased breath sounds, clubbing if chronic
  • Investigations may reveal:
    • Full blood count:
      • Leukocytosis
    • Chest X-ray:
      • Identifies consolidation with central cavitation and air-fluid level
    • Sputum and blood cultures:
      • Identifies causative agent
Coagulopathy or anticoagulant use
  • A history may reveal:
    • The use of an anticoagulant or recent thrombolysis
    • Easy bruising and epistaxis
  • A physical exam may reveal:
    • Bruising, petechiae
  • Investigations may reveal:
    • Coagulation assay:
      • May show prolonged INR
      • May show prolonged prothrombin time
Disseminated intravascular coagulation
  • A history may reveal:
    • Patients are generally seriously unwell (e.g. sepsis, trauma, amniotic fluid embolism, HELLP syndrome, malignancy)
    • Fever, cough, shortness of breath, epistaxis
  • A physical exam may reveal:
    • Bruising, petechiae, haematuria
  • Investigations may reveal:
    • Full blood count (FBC):
      • Thrombocytopenia
    • Blood smear:
      • Schistocytes
    • INR and activated partial thromboplastin time (APTT):
      • Increased INR and increased APTT
    • Fibrinogen:
      • Decreased
    • D-dimer:
      • Elevated
    • Fibrin degradation products:
      • Increased
Fat embolism
  • A history may reveal:
    • Usually due to long bone fracture or liposuction
    • Cardiorespiratory features: tachypnoea, tachycardia, hypoxia
    • Neurological features: changes in mental status (e.g. confusion/agitation), retinal haemorrhages
    • Dermatological features: petechial rash
    • Fever
  • A physical exam may reveal:
    • Fever, hypoxaemia, tachycardia, tachypnoea, altered mental state, petechiae, retinal haemorrhages
  • Diagnosis is clinical
Granulomatosis with polyangiitis (Wegener’s granulomatosis)
  • A history may reveal:
    • Upper respiratory tract – epistaxis, nasal crusting, sinusitis
    • Lower respiratory tract – haemoptysis, shortness of breath
    • Saddle-shaped nose deformity
    • General features – fever, malaise, weight loss, joint pain, anorexia 
  • A physical exam may reveal:
    • Sinus tenderness, saddle-shaped nose deformity
  • Investigations may reveal:
    • ANCA:
      • Positive
Anti-glomerular basement membrane disease (Goodpasture’s syndrome)
  • A history may reveal:
    • Haemoptysis and rapidly-progressing glomerulonephritis
    • Cough, fever, malaise
    • History of connective tissue disease
  • Investigations may reveal:
    • Anti-GBM antibodies:
      • Positive
Congenital heart disease
  • A history may reveal:
    • Progressive shortness of breath and features of heart failure including orthopnoea, paroxysmal nocturnal dyspnoea
  • A physical exam may reveal:
    • Heart murmurs, clubbing, cyanosis
  • Investigations may reveal:
    • Echocardiogram:
      • Identifies disorder
Airway trauma
  • A history may reveal:
    • History of trauma such as motor vehicle accident, blunt trauma to head or neck
    • May be iatrogenic following intubation, bronchoscopy, or endobronchial treatment
  • A physical exam may reveal:
    • Tachypnoea, chest or neck pain, wheezing 
  • Investigations may reveal:
    • Chest x-ray:
      • Widened mediastinum
    • CT chest:
      • Identifies trauma such as fractures and haematoma
Foreign body aspiration
  • A history may reveal:
    • Coughing and choking, ingestion of food
    • Recurrent pneumonia
  • A physical exam may reveal:
    • Unilateral wheezing, stridor, focal dullness to percussion
  • Investigations may reveal:
    • Chest x-ray:
      • May identify object
Aspergilloma
  • A history may reveal:
    • Most patients are asymptomatic but some may have cough and haemoptysis
  • Investigations may reveal:
    • Chest x-ray:
      • Upper lobe rounded opacity
    • CT chest:
      • Identifies upper lobe mass
    • Aspergillus precipitins titre:
      • Raised
Mitral stenosis
  • A history may reveal:
    • Chronic shortness of breath and haemoptysis
    • History of group A Streptococcus infection and rheumatic fever
  • A physical exam may reveal:
    • Mid-late diastolic murmur louder on expiration, opening snap, loud S1, loud P2, malar flush
  • Investigations may reveal:
    • Chest x-ray:
      • May show cardiomegaly
    • ECG:
      • May show atrial fibrillation
      • May show right ventricular hypertrophy
    • Echocardiogram:
      • Confirms diagnosis

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