Haemoptysis
Haemoptysis is the coughing up of blood or blood-stained sputum originating from the lower respiratory tract.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Acute bronchitis | Small amounts of blood-streaked sputum, recent URTI, self-limiting | 「最近有冇傷風感冒？」 | ~25% |
| Bronchiectasis | Chronic copious purulent sputum + haemoptysis, past pneumonia/TB | 「你平時有冇成日咳好多痰？以前有冇肺炎？」 | ~15% | |
| Serious Not To Miss | CA lung | Smoker, weight loss, persistent haemoptysis, hoarseness | 「有冇聲沙？體重有冇輕咗？」 | ~5% |
| Pulmonary TB | Fever, night sweats, weight loss, TB contact, DM | 「有冇出夜汗、發燒？有冇接觸過肺癆病人？」 | ~3% | |
| Pulmonary embolism | Pleuritic chest pain, acute SOB, DVT risk factors | 「有冇突然胸口痛加氣促？腳有冇腫？」 | ~1% | |
| NPC (Hong Kong-specific) | Epistaxis, neck mass, Chinese ethnicity | 「有冇流鼻血？頸有冇粒嘢？」 | < 1% | |
| Pitfalls | Pneumonia | Fever, productive cough, consolidation signs | 「有冇發高燒、痰變黃綠色？」Exam: bronchial breathing, dullness | ~5% |
| Mitral stenosis | Exertional dyspnoea, AF, loud S1, opening snap, mid-diastolic murmur | Auscultation: mid-diastolic murmur at apex | ~1% | |
| Foreign body | Acute onset, stridor (esp. children) | 「有冇嗆親嘢？」 | < 1% | |
| Masquerades | Drug-induced (anticoagulants/antiplatelets) | On warfarin/DOAC/aspirin | 「有冇食薄血丸或者亞士匹靈？」 | ~5% |
| Bleeding disorder | Bleeding from multiple sites | 「其他地方有冇出血？例如牙肉、皮膚瘀斑？」 | ~2% | |
| Trying to Tell Me Something? | Health anxiety / fear of cancer | Smoker or family member died of lung CA; excessive worry | 「你最擔心係咩？有冇嘢特別令你好驚？」 | ~10% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生。今日想同你傾下你嘅情況，會問你幾個問題，有咩唔明隨時話我知。」(Hi, I'm Dr X. I'd like to chat about your situation today, I'll ask some questions, feel free to stop me anytime.) | Interpersonal marks: greeting, introduction, permission |
| 0:30–2:30 | HPI – symptom analysis of haemoptysis | 「你幾時開始咳血？咳咗幾多血？係痰入面有血絲定係咳成啖血出嚟？」「痰係咩顏色？有冇膿痰？」「之前有冇嘔血或者流鼻血？」 | Completeness of HPI; distinguish true haemoptysis from haematemesis/epistaxis [1][2] |
| 2:30–3:30 | Red flags & systems review | 「有冇消瘦、出夜汗、發燒？」「有冇氣促、胸口痛？」「有冇腳腫？」「有冇食薄血丸？」 | Captures serious DDx: TB, CA lung, PE |
| 3:30–4:15 | PMH, Drug Hx, FHx, Smoking/Occupation | 「你有冇長期病？有冇食開咩藥？有冇藥物敏感？」「你食唔食煙？食咗幾耐幾多？」「你做咩工作？」 | Smoking = strongest risk factor for CA lung [3]; occupation for pneumoconiosis |
| 4:15–5:00 | ICE – uncover hidden agenda | 「你自己覺得咳血可能係咩原因？（Ideas）」「你最擔心嘅係咩？（Concerns）」「你今日嚟最希望醫生幫你做啲咩？（Expectations）」 | ICE marks; hidden agenda often = fear of lung cancer |
| 5:00–5:30 | Summarise & check understanding | 「等我總結一下：你咳血大概X日，有/冇痰⋯⋯有冇嘢我漏咗？」 | Shows active listening, completeness |
| 5:30–6:00 | Safety-net & close | 「如果你之後咳大量血、好氣促或者頭暈，一定要即刻去急症室。」「今日多謝你，有問題隨時再嚟搵我哋。」 | Safety-net = must for exam; warm closing |
Uncovering the hidden agenda: The patient's reason for consultation is often NOT haemoptysis itself but fear of lung cancer (especially if smoker/family history) or anxiety about TB (contact history). Ask: 「你點解揀今日嚟睇醫生？」(Why did you decide to come today?) — this single question often reveals the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Confirm true haemoptysis | Was the blood coughed up or vomited? Any nosebleed? | 「啲血係咳出嚟定嘔出嚟？有冇流鼻血或者牙肉出血？」 | Must distinguish from haematemesis, epistaxis, gum bleeding [1][2] | Haematemesis → GI source; epistaxis → ENT |
| Amount & duration | How much blood? Teaspoon/cup? How many days? | 「大概有幾多血？一茶匙定一杯咁多？咳咗幾多日？」 | Massive haemoptysis ( > 100 mL/day) = urgent [4] | Massive → bronchiectasis, CA lung |
| Sputum character | What colour is the sputum? Pus? Pink frothy? | 「痰係咩顏色？有冇膿？有冇粉紅色泡泡痰？」 | Bloody mucopurulent → bronchiectasis; blood-streaked → TB/CA; pink frothy → pulmonary oedema; rusty → pneumococcal [1][3] | See sputum DDx chart |
| Constitutional | Weight loss, night sweats, fever, appetite? | 「有冇消瘦？出夜汗？發燒？冇胃口？」 | TB, CA lung | TB if fever + night sweats + contact; CA if smoking + weight loss |
| Smoking Hx | Do you smoke? How many/day, how many years? | 「你有冇食煙？一日幾多支？食咗幾多年？」 | Smoking = major risk for CA lung [3] | CA lung, COPD, bronchitis |
| Respiratory symptoms | SOB? Chest pain? Wheeze? | 「有冇氣促？胸口痛？有冇喘？」 | Pleuritic pain → PE/pneumonia; SOBOE → HF | PE if pleuritic + DVT RFs |
| TB risk factors | TB contact? Travel? DM? HIV? Immunosuppression? | 「有冇接觸過肺癆病人？有冇糖尿？」 | DM, CKD, immunosuppression predispose to TB [5] | TB |
| DVT/PE risk | Leg swelling? Recent immobility/surgery/travel? OCP? | 「有冇腳腫？最近有冇做手術或者坐長途飛機？有冇食避孕藥？」 | PE = serious not to miss | PE |
| Drug Hx | Anticoagulants? Antiplatelets? ACEi? | 「有冇食薄血丸？亞士匹靈？」 | Drug-induced bleeding; ACEi causes cough (pitfall) | Bleeding tendency |
| Allergy | Any drug allergy? | 「有冇藥物敏感？」 | Safety; exam marks | — |
| Past Hx | Previous TB? Pneumonia? Heart disease? Cancer? | 「以前有冇肺癆、肺炎、心臟病？」 | Recurrence of TB; bronchiectasis post-infection | Bronchiectasis if recurrent pneumonia |
| Family Hx | Family TB? Lung cancer? | 「屋企人有冇肺癆或者肺癌？」 | Contact tracing for TB; cancer FHx | TB, CA lung |
| Occupation | What is your job? Dust/asbestos exposure? | 「你做咩工作？有冇接觸塵或者石棉？」 | Pneumoconiosis; mesothelioma | Occupational lung disease |
| Functional impact | Can you still work/exercise? Affect sleep? | 「咳血有冇影響你返工或者瞓覺？」 | Biopsychosocial assessment | Functional impairment |
Case Report Form Answer Builder
Write: "Haemoptysis × [duration]"
High-yield HPI points to capture:
- Onset, duration, frequency
- Amount (teaspoons vs cupfuls) and appearance (streaked / frank / clots)
- Sputum characteristics: bloody mucopurulent → bronchiectasis; blood-streaked → TB/CA; pink frothy → pulmonary oedema; rusty → pneumococcal [1][3]
- Confirm true haemoptysis (not haematemesis/epistaxis/gum bleed) [2]
- Associated: fever, night sweats, weight loss, SOB, chest pain, leg swelling
- Smoking history (pack-years), occupation, TB contacts, drug history (anticoagulants)
- Past respiratory history
Likely RFC examples:
- "Patient is worried about lung cancer because he is a smoker"
- "Patient is frightened by seeing blood in sputum"
- "Patient's wife insisted he comes because of persistent cough with blood"
Phrase as: "Concern about the cause of haemoptysis (worried about lung cancer)" — always link RFC to the patient's own words/motivation.
| Likely Content | Example Wording | |
|---|---|---|
| Ideas | "I think I might have lung cancer" / "Maybe TB" / "Just a bad chest infection" | Patient thinks haemoptysis may be due to lung cancer given his smoking history. |
| Concerns | Fear of cancer/death; fear of TB transmission to family; worry about missing work | Patient is worried he has lung cancer and may die. |
| Expectations | Wants CXR or referral; wants reassurance; wants antibiotics | Patient expects a chest X-ray today and referral to specialist if needed. |
Choose based on stem clues:
| If Stem Says… | Most Likely Dx | Minimum Supporting Evidence |
|---|---|---|
| Chronic smoker + weight loss + persistent streaky haemoptysis | CA lung | Smoking ≥ 20 pack-years, weight loss, blood-streaked sputum [3] |
| Chronic copious purulent sputum + recurrent infections + haemoptysis | Bronchiectasis | Hx of previous pneumonia/TB, daily sputum, clubbing [6] |
| Fever + night sweats + weight loss + TB contact | Pulmonary TB | Contact Hx, constitutional symptoms, subacute onset [5] |
| Acute SOB + pleuritic pain + recent immobility | Pulmonary embolism | DVT risk factors, pleuritic chest pain [7] |
| DDx | One Key Discriminator |
|---|---|
| CA lung | Persistent haemoptysis in smoker with weight loss and hoarseness |
| Pulmonary TB | Subacute fever, night sweats, weight loss, TB contact/DM |
| Bronchiectasis | Chronic copious mucopurulent sputum, recurrent infections, clubbing |
| Pulmonary embolism | Acute pleuritic pain + SOB, DVT risk factors, leg swelling |
| Pneumonia | Acute fever, productive cough, signs of consolidation |
(Pick three that are NOT your most likely diagnosis.)
| Domain | Example |
|---|---|
| Biological | Haemoptysis requiring investigation to exclude malignancy/TB; smoking-related lung damage |
| Psychological | Anxiety and fear of lung cancer; sleep disturbance due to worry |
| Social | Unable to work due to symptoms; concern about TB transmission to family members; financial stress from potential hospitalisation |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| CA lung | Finger clubbing [4]; or supraclavicular lymphadenopathy | Inspect nail beds for loss of nail-fold angle; palpate bilateral supraclavicular fossae | Clubbing a/w CA lung and suppurative lung disease; SCL LN = metastasis |
| Bronchiectasis | Finger clubbing + coarse inspiratory crackles [6] | Auscultate lung bases; check if crackles clear with coughing | Coarse crackles that shift with coughing = secretion-related (bronchiectasis) |
| Pulmonary TB | Reduced breath sounds / crackles at apex | Auscultate apices; percuss for dullness | Post-primary TB classically affects upper lobes [5] |
| Pulmonary embolism | Unilateral leg swelling (DVT signs) | Measure bilateral calf circumference; check for warmth, tenderness | DVT is the source of PE in > 80% of cases [7] |
| Pneumonia | Bronchial breathing + dullness to percussion | Percuss and auscultate affected zone | Signs of consolidation |
| Acute LVF | Bilateral fine basal crackles + S3 gallop | Auscultate lung bases and cardiac apex | Pulmonary oedema causes pink frothy sputum |
Top Traps That Lose Marks
- Failing to confirm TRUE haemoptysis — always ask: was it coughed up (with sputum) or vomited? Any nosebleed or gum bleeding? [1][2]
- Forgetting to ask smoking history — this is THE strongest risk factor for CA lung and is almost certainly in the stem.
- Missing ICE — the hidden agenda is usually fear of lung cancer. If you don't ask ICE, you lose marks on Q2, Q3, and interpersonal skills.
- Writing "haemoptysis" as the RFC — RFC is the patient's reason, not the symptom. E.g., "worried about lung cancer" or "wife told him to come."
- Not asking about anticoagulant/antiplatelet use — a masquerade cause of haemoptysis.
- Confusing bronchiectasis crackles with pneumonia crackles — bronchiectasis crackles are coarse and clear with coughing; pneumonia crackles do not.
Must-Not-Miss Red Flags → Urgent Referral
- Massive haemoptysis ( > 100 mL/day) → A&E immediately; lie on bleeding side; secure airway [4]
- Haemoptysis + weight loss + smoker → urgent CXR + CT + bronchoscopy to exclude CA lung [3]
- Haemoptysis + fever + night sweats + contact → sputum AFB × 3 mornings; isolate patient
- Haemoptysis + acute SOB + pleuritic chest pain → CTPA to exclude PE [7]
- Haemoptysis + haematuria → think pulmonary-renal syndrome (Goodpasture's, GPA) → urgent referral
Shortest safe management/safety-net line:
「如果你之後咳大量血、好辛苦抖唔到氣、或者頭暈企唔穩，一定要打999即刻去急症室。我會安排你照肺片同埋驗痰，結果出咗之後會再跟你講。」
(If you cough up large amounts of blood, can't breathe, or feel faint, call 999 and go to A&E immediately. I'll arrange a CXR and sputum test, and follow up with results.)
Investigation pathway for haemoptysis (GC high-yield): CXR → CT thorax with contrast → Bronchoscopy [1][4]. Sputum for C/ST, AFB stain/culture, cytology. Bloods: CBC, clotting, CRP/ESR, T&S. If PE suspected: D-dimer → CTPA [7].
High Yield Summary
What to ASK: Confirm true haemoptysis → sputum character → amount/duration → constitutional symptoms → smoking → TB risk → PE risk → drugs (anticoagulants) → ICE (fear of lung cancer is the hidden agenda)
What to WRITE: Chief complaint = "Haemoptysis × [duration]"; RFC = patient's own reason (e.g., fear of cancer); ICE clearly stated; Most likely Dx with supporting evidence; 3 DDx each with one discriminator; Biopsychosocial problems; Physical sign = clubbing (CA/bronchiectasis) or SCL LN (CA) or apical signs (TB)
What NOT to MISS: True vs pseudo-haemoptysis; smoking history; massive haemoptysis red flag; ICE/hidden agenda; anticoagulant use
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: General clerkship Teaching Clinic - Haemoptysis_Prof MSM Ip_25 October 2024.pdf (p.44, p.47) [2] Lecture slides: Respiratory Four cases of Haemoptysis.pdf (p.39, p.42) [3] Lecture slides: Respiratory Four cases of Haemoptysis.pdf (p.42); Senior notes: Ryan Ho Respiratory.pdf (p.141-142) [4] Senior notes: Ryan Ho Respiratory.pdf (p.22-23); Senior notes: Maksim Medicine Notes.pdf (p.280) [5] Senior notes: Ryan Ho Respiratory.pdf (p.75); Senior notes: learning_points_output.txt (Respiratory - Four Cases of Haemoptysis) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.182-184); Lecture slides: GC 052. Fever and purulent sputum.pdf (p.41) [7] Senior notes: Ryan Ho Respiratory.pdf (p.133); Past papers: 2018 Fourth Summative MCQ.pdf (Question 7)
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