01 Haemoptysis should be investigated in smokers over 40.
02 Do not ignore shoulder pain in smokers over 40.
03 Weight loss and night sweats may be due to tuberculosis.
04 Falling asleep while driving or at work may be due to obstructive sleep apnoea.
05 Not all wheezing is caused by asthma.
06 An asthmatic who wakes at night with cough and wheeze is at risk of a life-threatening attack.
07 Early morning headache in a patient with lung disease may be due to carbon dioxide retention.
08 A stuffy nose with chest symptoms could indicate Wegener’s granulomatosis.
09 Do not forget to ask about the budgie!
10 An asthmatic with nasal polyps might be hypersensitive to NSAIDs.


1 Haemoptysis

Coughing up blood is an alarming symptom but does not necessarily imply serious underlying lung disease. It can be difficult, therefore, to know how extensively to investigate the patient. In a patient at low risk for lung cancer, with isolated haemoptysis, no further action is usually required if the CXR is normal. Conversely, further investigation is needed in smokers over the age of 40, as approximately 2% will be found to have a tumour.
Repeated haemoptysis should always be investigated regardless of the CXR findings and risk factors for lung cancer.
Although rare, non-smokers may develop lung tumours. Other possible diagnoses include bronchiectasis, which can
be difficult to detect on a CXR, and pulmonary embolism, particularly following immobilisation or recent travel.

Action: Arrange urgent CXR. Refer to the chest clinic, urgently in smokers over 40.

2 Pancoast’s tumour

Tumours arising from the apex of the lung may grow into the chest wall and brachial plexus, and are known as Pancoast’s tumours. They characteristically cause excruciating pain in the shoulder and inner aspect of the arm but may be mistaken for minor shoulder conditions. Other features of Pancoast’s tumours are Horner’s syndrome, loss of sensation in the T1 dermatome and weakness of the small muscles of the hand. Pancoast’s tumours are easily missed on plain X-rays and the patient should still be referred if clinical suspicion persists.

Action: Examine for the features above and arrange urgent CXR. Refer urgently to the chest clinic.

3 Tuberculosis

TB is becoming increasingly common both worldwide and in the UK. Individuals at particular risk include immigrants from countries where the disease is endemic, alcoholics, patients with HIV and healthcare workers. A history of weight loss and night sweats may indicate active disease. Productive and persistent cough is the commonest respiratory symptom.

Action: Ask about risk factors and possible TB contacts. Arrange CXR, and check FBC, ESR and CRP. Refer to a TB clinic directly if the CXR is suggestive of TB. If uncertain, refer to a chest clinic, as other possibilities, such as lymphoma, may need to be excluded.

4 Obstructive sleep apnoea

Obstructive sleep apnoea classically affects middle-aged, overweight men with short necks. Their partners may complain that they snore loudly and they may even notice that they develop apnoeic episodes while asleep. As a result of their poor quality of sleep, they may have trouble concentrating during the day and may even fall asleep at work. This may have profound effects on their professional and personal lives and can result in tragedy if they fall asleep while driving or operating machinery.

Action: Refer to a sleep clinic. Offer advice to lose weight (if appropriate) and to avoid drinking alcohol or taking a sedative at night. Advise not to drive or work with machinery if there is a risk of falling asleep.

5 Non-asthmatic wheeze

The diagnosis of asthma is usually clinical and based on relatively non-specific symptoms. However, other organic diseases (e.g. lung cancer, chronic obstructive pulmonary disease (COPD), cardiac failure and some laryngeal conditions) may mimic asthma by causing breathlessness and wheeze. In addition, psychogenic conditions, associated with hyperventilation and disproportionate breathlessness, may also be mistaken for asthma. None of these respond to standard asthma treatment and failure to improve should prompt a search for an alternative or additional diagnosis.

Action: Reconsider the diagnosis in an ‘asthmatic’ who fails to respond to treatment.

6 Uncontrolled asthma

Young asthmatics are more likely to have brittle disease and to ignore their symptoms, with tragic consequences. A history of waking at night with cough and wheeze is an important indicator of poorly controlled asthma. Many asthmatics are reluctant to take inhaled corticosteroids and rely exclusively on their bronchodilators. They may obtain temporary relief before going to bed but wake a few hours later with very severe bronchospasm.

Action: Refer urgently to the chest clinic. Emphasise the importance of taking steroid inhalers regularly. If the patient is severely breathless and wheezy, refer immediately to casualty.

7 Carbon dioxide retention

Carbon dioxide retention may develop insidiously and can be easily overlooked. It is important to diagnose as it may lead to narcosis and death. Characteristically, patients complain of severe headaches on waking in the morning. Patients at risk include those with COPD (who may be on long-term oxygen therapy) and those with severe kyphoscoliotic deformities and neuromuscular disease. This latter group may also report breathlessness on lying flat.

Action: Refer urgently to the chest clinic or to a dedicated sleep clinic.

8 Wegener’s granulomatosis

Wegener’s granulomatosis is an uncommon necrotising vasculitis that affects particularly the upper airways, lungs and kidneys. The upper airway symptoms may be minor and mentioned only as an afterthought, as patients concentrate on the cough, haemoptysis and symptoms associated with renal disease or cutaneous vasculitis. Symptoms of nasal stuffiness should not be overlooked as they may provide a clue to diagnosing this otherwise elusive multisystem disease. The diagnosis is usually established from the presence of characteristic antibodies in the blood.

Action: Check serum antineutrophil cytoplasmic antibody (ANCA). Refer urgently to the chest clinic.

9 Extrinsic allergic bronchiolo-alveolitis

Extrinsic allergic bronchiolo-alveolitis is most easily identified from the acute flulike symptoms that develop a few hours after exposure when individuals have intermittent contact with the causative agent. Patients who live with a budgerigar at home tend to have chronic low-level exposures and can develop more insidious pulmonary fibrosis without obvious acute episodes – the chronic form of the disease. Breathlessness is accompanied by absent or few physical signs. Finger clubbing is rare. The diagnosis can usually be established from serum IgG antibodies (precipitins) and CT abnormalities, but will be missed unless the pets are enquired about.

Action: Check serum avian precipitins. Refer to the chest clinic.

10 Aspirin-sensitive asthma

About 2% of asthmatics report some degree of aspirin sensitivity. It is more common in women, those with adult onset of disease and those with severe unstable asthma. The response to ingesting aspirin or other NSAIDs can be dramatic, with life-threatening bronchoconstriction developing within minutes. About 60% of patients with aspirin-sensitive asthma have nasal polyps. Caution should therefore be exercised in prescribing NSAIDs to an asthmatic with this finding. Aspirin and other NSAIDs should be avoided completely if there is a history of a previous adverse reaction.

Action: Avoid prescribing aspirin and other NSAIDs to asthmatics with nasal polyps or a history of previous adverse reactions.