A patient with hemoptysis presented to our hospital while i was on call , so i prepared the case and its details as a powerpoint presentation to reviwe the case in the morning report

1. by: Dr.Ayah Yazeed Soroghli
Internal medicine resident-1st year
Al-Watani hospital -Palestine
Case Presentation

2. Patient ID
 R.D
 20 year old
 Married
 G3P4A0 , lactating
 Has 4 offsprings
 housewife

3.  Baseline status:
 Unlimitted exercise tolerance
 CC: blood-streaked sputum for 5 days of duration

4. History of presenting illness
 Sudden onset ,first time
 prior 5 days of admission
 Intermittent in frequency
 Fresh blood mixed in clear sputum
 Half cup of urine per/day
 Associated with intermittent SOB
 Not associated with fever , cough , chills , chest pain or purulent
sputum .

5.  Hx of frequent cough and sputum production , but
mostly in active infectious disease .
 Hx of flu-like illness 2 weeks ago (severe cough
,fever,chills , generalized weakness) , lasts few days
then resolved .
 Hx of uncomplicated CS for 3 months ago .
 Hx of recurrent infections since child hood
 Pt have menses .

6. Related Negative symptoms
 No hx of melena , hematomesis or abdominal pain .
 No hx of orthopnea , PNDs or claudications
 No hx of bleeding from the nose or gums .
 No hx of rash or ulcers .
 No hx of weight loss , night sweats , bone pain ,
arthralgia
 No hx of hematuria , dysurea , frequency or urgency .
 No hx of smoking ,alcohol or substances indigestion .
 No hx of recent surgeries , immobilization , for the
lase 12 weeks.
 No hx of previous DVT , or unilateral limb swelling .
 No hx of travel
 No hx of recurrent abortions

7. Cont,
 No hx of exposure to asbestos , organic
chemicals .
 No hx of exposure to TB patients .
 No hx of foreign body inhalation
 No hx of trauma

8.  PMHX : free
 no known or suspected pulmonary, cardiac, or renal disease
 No known or suspected bleeding disorder?
 Recurrent upper respiratory tract infection
 PSHX : free
 Hx of Cs , 3 months ago , uncomplicated , no long
immoblization
 No hx of thoracic procedure (eg, stent placement,
pulmonary artery catheter, aortic graft).
 Drug hx : free
 Like aspirin, nonsteroidal anti-inflammatory drugs, anti-
platelet drugs, or an anticoagulant

9.  Family hx :
 No family members had similar symptoms .
 No problems with blood clots
 No family hx with brain aneurysms, epistaxis, or
gastrointestinal bleeding (suggesting possible
hereditary hemorrhagic telangiectasia)?
 No hx of TB

10. Social hx
 Non smoker
 Well-ventilated house

11. PHYSICAL EXAMINATION
Vital signs :
T: 36, BP:105/70, HR:102 , SAT O2:96%
 -General : looks well, not tachypnic , not in respiratory
distress
 -Neck : JVP flat
 -Chest: good breath sounds
 -Heart: normal S1 , S2 , no added sounds
 -Abdomen:
 Soft lax abdomen
 No Tenderness
 No masses
 no Lower Limb edema
 no palpable cervical or Axilary LNs

12. Investigations
 Full labs (CBC, u/a,LFT,KFT , electrolytes)
 Covid rapid
 Abgs
 ECG (S1Q3T3)
 CXR
 HRCT

13. LABS
 CBC :
 Hgb:12.2
 Wbc:4.7 , diff;
 Plt:307
 Cre:0.65 , BUN: 11
 CRP:0.6
 LFT : normal except
 GGT : 2495! Repeated twice in different samples ,
no old recordings
 ALP:140
 Bill total:0.3 normal , direct:0.1 normal

14.  Electrolytes and RBS within normal
 Albumin : 4.27
 Pt:12 , Ptt:27 , INR:1
 Urine analysis : free , slight RBCs due to menses
 D-Dimer : 0.1 negative
 Troponin : 0.00 negative
 Immunoglubulins within normal ranges
 RF , ANA , TSH : pending result
 Hepatitis profile : pending result

15. Abgs
 Normal , PH:7.38 , Pco2:53 , Hco3:20 , Po2:97
 Osmality serum : 296
 Osmolality gab = 11

16. Chest x-ray

17. HRCT scan
 Reviewed by System

18. Initial Impression
 Bronchitis (still highly suspected and on top of
deferential)
 R/O PE
 Mild risk for PE (well’s criteria : 0) ,D-dimer =0.1
 RO Valvular Herat disease (waiting ECHO)
 Cholestasis suspected for investigation (severe high
GGT)
 R/O alfa anti-trypsine deficiency or cystic fibrosis
(liver , lung ? )
 Catamenial hemoptysis ??

19.  The expectoration of blood, can range from
blood-streaking of sputum to the presence of
gross blood in the absence of any accompanying
sputum.
 Had broad differential .
 It is important to identify the cause and location
of bleeding in order to guide treatment
 massive hemoptysis : 500ml/day or rate
>100ml/hr

20.  Blood originating from below the vocal cords can
best be categorized according to the site of
bleeding (ie, airways, lung parenchymal,
pulmonary vascular, cryptogenic)
 Pulmonary vs bronchial artries .
 Pseudohemoptysis : Blood from the upper
respiratory tract and the upper gastrointestinal
tract .

21. Common causes of hemoptysis
 In developed countries
 Bronchitis
 bronchogenic carcinoma
 bronchiectasis
 In endemic countries
 infections due to Mycobacterium tuberculosis
and Paragonimus westermani .

22. Causes by Location :
 Airway diseases
 Airway trauma
 Bronchitis: Acute or chronic
 Bronchiectasis*, including cystic fibrosis
 Bullous emphysema
 Bronchovascular fistula (eg, aortic aneurysm with
erosion into airway)
 Neoplasms
 Bronchial adenoma
 Bronchogenic carcinoma
 Dieulafoy disease (subepithelial bronchial artery)
 Metastatic cancer to bronchus or trachea
 Foreign body in airway

23.  Pulmonary parenchymal Diseases
 Infection
 Anthrax
 Lung abscess
 Mycetoma other fungal infections
 Necrotizing pneumonia
 Parasitic (eg, Paragonimus westermani*)
 TB

24.  Rheumatic disease
 Amyloid
 Anti-glomerular basement membrane disease (Goodpasture
disease)
 Behçet's disease
 Granulomatosis with polyangiitis (Wegener's) and other
vasculitides
 Primary antiphospholipid antibody syndrome
 Systemic lupus erythematosus

25.  Genetic disorders of connective tissue –Ehlers-
Danlos syndrome, vascular type .
 Coagulopathy – A coagulopathy, such as
thrombocytopenia or use of anticoagulants .
 Iatrogenic
 Miscellaneous causes : Cocaine-induced ,
Catamenial hemoptysis (with menses)

27.  Pulmonary vascular diseases
 Pulmonary embolism (eg, fat, septic, thrombotic)
rare
 Congenital heart disease
 Heart failure
 Mitral stenosis
 Tricuspid endocarditis
 Pulmonary arteriovenous
 malformationPulmonary artery
 pseudoaneurysm
 Pulmonary veno-occlusive disease

28.  Disorders of coagulation
 Anticoagulant and antiplatelet medications
 Disseminated intravascular coagulation (DIC)
 Platelet dysfunction
 Thrombocytopenia (ITP, TTP, HUS)
 von Willebrand disease

29.  Cryptogenic — up to 30 percent of patients with
hemoptysis have no cause identified even after
careful evaluation including bronchoscopy.
 These patients are classified as having either
cryptogenic or idiopathic hemoptysis .

30. INITIAL EVALUATION
 Taking Hx .
 Physical examination
 Examination of sputum
 respiratory distress
 Auscultation of lungs – focal wheeze or diffuse crackles?
 Auscultation of heart – murmur of mitral stenosis or
mitral regurgitation?
 Skin), palpable purpura or other rash suggestive of
vasculitis?
 Extremities –peripheral edema, joint effusions or
periarticular warmth?
 Labs
 imagings
 Bronchoscopy

31. LABS
 CBC (hct , hgb , WBC , PLT)
 Urine analysis (pulmonary –renal syndromes)
 KFT
 LFT and coagulopathy profile
 Vasculitis profile

32. Imaging
 CXR (initial test)
 HRCT
 Bronchoscopy