Hemoptysis: Causes and relevant question.

All the information below can be referred to Harrisons text book of Medicine.

What is hemoptysis ?

Hemoptysis is the expectoration of blood from the respiratory tract.

What can hemoptysis be confused with?

Hematemesis and epistaxis

What are the causes of Hemoptysis?

Tracheobronchial (Airway )	Parenchymal (Lungs)	Cardiogenic	Vascular	Miscellaneous
Carcinoma (bronchogenic, endobronchial, metastatic)	Tuberculosis (most common cause globally)	Mitral Stenosis	Pulmonary embolism	Systemic Coagulopathy
Acute/ Chronic Bhronicitis	Pneumonia	Left Heart failure	Raised pulmonary venous pressure (Mitral stenosis)	Anticoagulant/ Antiplatelet therapy
Bronchoectasis	Lung Abscess			Pulmonary Endometriosis (Catamenial  Hemoptysis )
Airway trauma	Wegener Granulomatosis			Endobronchial Biopsy (Iatrogenic)
Foreign Body	Good Pasture syndrome
Nasopharyngeal bleeding	Lung Contusion
	Inhalational Injury (Burn, Smoke, Toxin, Cocaine)

Bold are very important causes and MUST say causes of hemoptysis.
Red one is the most important of all.

What is the source of hemoptysis?

Medium and large sized airway of Lungs in close proximity to bronchial artery and vein.

Which pneumonia are associated with hemoptysis?

Tuberculosis with cavitary lesions (Most common)

CAP with cavitary lesions (Staphylococcus aureus, Klebsiella )
COPD patient (Streptococcus pneumonaie, H. Influenzae, Moraxella catarallis)

Which Carcinoma of lungs are more likely to cause hemoptysis? Why?

Squamous cell carcinoma and small cell carcinoma

These are large Cancers arising from proximal airway and centrally located and hence can produce hemoptysis.

Why there is hemoptysis in Mitral stenosis/ Congestive Heart Failure?

Congestive heart failure with transmission of elevated left arterial pressure, if severe enough can lead to rupture of small alveolar capillary. Thus hemoptysis is rarely frank bright red, rather it is pink frothy sputum or blood tinged secretions.

What is massive hemoptysis?

Hemoptysis greater than 200-600 ml in 24 hours. It is a medical emergency as patient can exsanguinate and drown on his own aspirate.

What is the source of profuse hemoptysis?

Massive hemorrhage can occur if the source of the blood is from the high pressure systemic circulation that is the BRONCHIAL ARTERY. But the bleeding is not so massive if the source is low pressure pulmonary circulation that is alveolar capillary bleeding.

Source: Harrison

 

Causes of Hemoptysis

Causes of Splenomegaly: Etiology and pathology

Enlargement of the size of the spleen beyond its normal shape and size and position is defined as splenomegaly. The normal anatomy of spleen is defined as a structure of 1inch x 3 inch x 5 inch, with weight of 7 ounces (~150-200g) in size and spans across 9-11 ribs in the left upper quadrant of the abdominal cavity. This is the rule of odd number in spleen (1, 3, 5, 7, 9, and 11).

Etiological Causes of Splenomegaly

The size of the spleen has to increase by at least 500g to called splenomegaly and has to be more than 1000g to define as massive splenomegaly. It is not necessary that every enlarged spleen will be palpable by clinical examination. The size of the spleen has to increase by 3-5 folds to be appreciated clinically. In terms of size it has to be greater than 10-11 cm in its greatest diameter to be defined as moderate splenomegaly and more than 20 cm in its largest dimension to be called as massive splenomegaly.

The cause of splenomegaly can be classified as either etiological causes or pathological cause.

Dividing the causes of splenomegaly etiologically, it could either be infective, hematological, metabolic, collagen vascular disease or other various causes. The most important one are obviously the infective and the hematological causes.

Infective causes of splenomegaly

Bacteria such as salmonella typhi/paratyphi, scrub typhus, mycobacterium tuberculosis, pneumococcal splenic abscess and septicemia by any organism can cause splenomegaly. HIV and EBV (infectious mononucleosis) are the viral causes of splenomegaly. Malaria and Schistosomiasis are few tropical protozoal disease to cause splenomegaly. Parasites like Leshmania donovani (kalazar) and echinococcus (hydatid cyst) are other causes. Syphilis and Weils (Leptospirosis) disease are some spirochetal conditions associated with splenomegaly.

Hematological causes of splenomegaly

Hematological causes may be related to RBC, WBC or platelet. The condition where there is massive RBC destruction or massive extra medullary hemopoeisis is associated with splenomegaly. Most of the hemolytic causes of anemia such as hereditary spherocytosis, autoimmune hemolytic anemia, thalassemia, sickle cell disease, erythroblastosis fetalis have splenomegaly. Similarly faulty RBC synthesis in pernicious anemia leads to increased load in spleen to cause hemolysis. The polycythemia is associated with increased extra hemopoeitic synthesis of RBC. The Leukemia including  CML, ALL, AML, CLL will have splenomegaly. ITP also has splenomegaly.

Splenomegaly Causes other than infection and blood related

Metabolic causes such as rickets, Gaucher’s, porphyria, amyloidosis present with enlarged spleen clinically.  Infarction of spleen, portal hypertension associated with pancreatic carcinoma and splenic vein thrombosis are some of the circulatory or vascular causes. Collagen vascular diseases as Still's disease and Felty syndrome are other causes.  Non paracytic cyst either congenital or acquired cause splenomegaly.

Angioma , primary fibrosacroma, Hogdkins lymphoma, myelofibrosis are other lymphomas are the neoplastic causes of the condition. 

Causes of altered sensation of Smell

Learn how to examine the sense of smell.

Anosmia (No smell)

Atrophic rhinitis

Peripheral neuritis

Degenerative Disease of Nose

Injury to factory nerve

Injury to olfactory bulb

Anterior Cranial fossa fracture

Intracranial abscess

Intracranial tumors

Meningitis

Causes of various types of Nasal discharge.

Parosmia (Perversion of smell)

Recovery Phase of post influenza anosmia

Intracranial tumor

Clinical Examination of Nose and PNS

Hyposmia (Decreased Smell)

Nasal Polyp

Enlarged Turbinate

Edema of Mucosal Membrane

Common cold

Vasomotor Rhinitis

Allergic Rhinitis

Strawberry Sign In Medicine

Strawberry cervix:  trichomoniasis. (Trichomonas vaginalis)

erythematous cervix with pinpoint areas of exudation

Strawberry gallbladder: cholesterolosis

Change in the gall bladder bladder wall due to excessive Cholesterol

Strawberry gingivitis/gums:  

Wegener's granulomatosis: immunologically mediated uncommon multisystemdisorder affecting aerodigestive tract

Sarcoidosis

Strawberry nevus/hemangioma: capillary hemangioma
benign condition appearing after birth characterized by endothelial prolifeartion 

Find all the terms named after Kocher 

Strawberry tongue:

Glossitis with hyperplastic fungiform Papillae
Scarlet Fever :GABH Streptococcus Infection
kawasaki disease: Vasculitis seen in Children
Toxic Shock Syndrome: Fatal illness caused by toxins of Staphylocccus aureus and streptococcus Pyogenes

Strawberry Shaped Nasal Mass: rhinosporidiosis

Chronic granulomatous disease caused by Rhinosporidium seeberi, characterised by production of polyps and other manifestations of hyperplasia of nasal mucosa

Strawberry skin : sarcoidosis

Strawberry shaped skull: 
Edward syndrome 

Trisomy 18

Differntial Diagnoses in Nose

Nasal Polyp	Nasal mass
Antrochonal Polyp	Blob of mucous
Juvenile Nasal Angiofibroma	Rhinosporiodosis
Glioma	Antrochonal Polyp
Hemangioma	Rhinoscleroma
Encephaloceles	Rhinolith
Papilloma	Hypertrophied turbinates
	Malignancy
	Septal Hematoma

Learn describing the Nose and PNS during the OSCE and  Clinical Skill  examination.

Crust in Nose

Atrophic Rhinitis

Rhinoscleroma

Rhinitis Sicca

TB

Syphillis

Septal Perforation

Rhinosporiodosis

Any granulomatos disease of nose

Differential diagnoses of various types of Nasal discharge.

Membrane over nose

Bacterial Rhinitis

Diptheria

Aspergillosis

Causes of altered sensation of Smell

Itching  over nose

Myiasis

Allergic Rhinitis

Differential Diagnoses in Ear

Differential Diagnoses in Ear

Polyp In EAR	Character
CSOM TT	Pale
CSOM AA	Red Fleshy
Glomus Tumor
Perforating TB

Purulent Ear Discharge

Diffuse otitis Externa

Primary Cholesteatoma of External Ear Canal

Acute Coalascent Mastoiditis

ASOM (Reservior Sign)

Petrositis

Infected Glomus tumor

 

Itching in Ear

Diffuse Otitis Externa

Eczematous Otitis Externa

Otomycosis

Seborrhagic Otitis Externa

Neurodermatitis

Blood Stained discharge from ear

Otitis Externa Hemorrhagica

Middle Ear Carcinoma

CSOM AA

Trauma to External Ear

ASOM in the stage of Resolution temporal Bone fracture

Foul smelling discharge from Ear

CSOM AA

Otomycosis

TB

Carcinoma Middle Ear

Carcinoma Mastoid

Crust in Ear

Eczematous Otitis Externa

CSOM AA

Chronic Diffuse Otitis Externa

Fluctuating Hearing loss

Meniere's Disease

Perilymph Fistula

Autoimmune

Syphillis

Malingering

Minor Ear Disorders

Satyr Ear

Darwin Tubercle

Stahl's ear

Absent Tragus