Clinical reasoning 11/11/2015

Blood

coughing case 1
50 y.o.
coughs up sputum with sporadically blood
smoked pack a day for 20 years
no fever no pain, eats normal, bit of weight loss
coughs especially in morning and last 3 months coughs daily, voice
unchanged
no allergies
went to Zeeland on a holiday
no nail clubbing, no lymphadenopathy
diffuse rales
no palpable organs, no further findings

DD:
1. Lung cancer
a. Cough, dyspnea, hemoptysis, weight loss
b. CXR, CT or PET-CT with FDG
c. Peripheral tumour: bronchoscopy
d. Central tumour:
2. Tuberculosis (not to foreign TBC country)
3. COPD
4. Bronchiectasis
5. Airway infection (no fever)
a. Pneumonia
6. Varicose vein
7. Gastric ulcer (you would see more blood and loss of appetite)
8. Pulmonary embolism immediately referring to pulmonologist
a. Christopher criteria
b. D-Dimer
c. CT
9. Thoracic trauma
10.Foreign body inhalation
11.(burns)
12.other cancers
13.Langerhans cells histiocytosis
Questions:
Overall malaise: fever, weight loss etc.
Family history
Medication
Alcohol consumption (oesophageal problems)
Travel
PE:
Look in mouth
Percussion and auscultation
Check the lymph nodes (supraclavicular zone)
Blood pressure, oxygen saturation
Origin:
- epistaxis

- lungs
- mouth
- oesophagus
- stomach
cause:
medication, trauma, pain (mouth)
case 2
Haemoptysis, no fever or pain, good appetite, no allergies, holiday to spain and
Italy (no TBC)
grey dyspnoeic patient, no clubbing or lymphadenopathy, diffuse rales.
Non smoker (<100 cigarettes in life)
1. Lung cancer
a. Treated with targeted therapy: EGFR-TKI (erlotinib, gefitinib, afatinib)
b. adenocarcinoma
2. Tuberculosis (not to foreign TBC country)
3. COPD
4. Bronchiectasis
5. Sarcoidosis
6. Airway infection (no fever)
a. Pneumonia
7. Varicose vein
8. Gastric ulcer (you would see more blood and loss of appetite)
9. Pulmonary embolism immediately referring to pulmonologist
a. Christopher criteria
b. D-Dimer
c. CT
10.Thoracic trauma
11.Foreign body inhalation
12.(burns)
13.other cancers
14.Langerhans cells histiocytosis