Case Questions:

  1. What historical questions do you want to ask about the hemoptysis; what diagnoses are suggested by each? 

The patient denies any history of respiratory problems. He has had no recent colds or fevers/chills. He states he simply has a "smoker's cough". He has had no recent trauma, but traveled to Mexico approximately 3 months ago. He states he has been watching his diet and has lost 30# in the last 6 months. He is on no medications. He has a 60 pack year tobacco history and continues to smoke approximately 1.5-2 ppd. He has coughed up about 60cc (two tablespoons) of bright red blood, mixed with gray sputum, several times over the past two days. He has no chest pain, but feels an uncomfortable sensation in his right chest prior to bringing up sputum. He denies history of epistaxis, bleeding gums, or melena/hematochezia.

  1. What is meant by a "smoker's cough" ? What is the significance? What questions should you ask about a smoker's cough? How long does it last after smoking cessation?
  2. What physical findings are you specifically going to look for, and why? 

His blood pressure is 142/88, RR is 16, HR 96; he is not orthostatic. Oxygen saturation by finger pulse oximeter is 92% on room air. HEENT exam reveals no obvious bleeding source. Lungs reveal basal crackles bilaterally, prolonged expiratory phase, and rare scattered wheezes bilaterally. The abdominal exam is unremarkable, stool for occult blood is negative, and there is no clubbing or cyanosis of the extremities. Skin is without lesions. 

  1. What is your differential diagnosis now? 
  2. What diagnostic studies will you order first, and why? 

His chest X-ray is read as consistent with emphysema, with a focal infiltrate in the right lower lobe. CBC: WBC 12,000/mm3, Hgb 14, Hct 44, platelet count 390K/mm3. Coagulation profile is normal.

Arterial blood gas: pH 7.43/pCO2 36/pO2 65/Sat 92% on room air. Sputum examination reveals many rbcs, few (<10/lpf) squamous epithelial cells, >25 WBC/hpf, gram negative rods and gram positive cocci. AFB smear is negative. Cytology is sent. PPD is placed.

 

  1. How do you interpret the chest X-ray? the CBC? the sputum results? the ABG?
  2. What CXR findings suggest emphysema? 
  3. What is your differential diagnosis now, and why? 
  4. What do you plan to do with the patient now?
  5. What are indications for intensive care unit admission? 
  6. How do you assess the quality of the sputum sample? 

The patient coughs up approximately 100cc more of bright red blood. You admit him to the Medical Intensive Care Unit in respiratory isolation. He receives codeine to suppress his cough, and antibiotics for community acquired pneumonia. Pulmonary medicine consultation is obtained for possible bronchoscopy. His bleeding seems to slow down again. Cardiovascular surgery is notified. AFB smears are negative times three. PPD is nonreactive.  

 

  1. What measures can you take to ensure adequate oxygenation and prevent asphyxiation? 
  2. Why is the patient in respiratory isolation? What information is necessary to free patient from isolation? 
  3. What are general indications for fiberoptic vs. rigid bronchoscopy for localization of bleeding site?
  4. What is the definition of massive hemoptysis? 
  5. What is the blood supply to the lungs? From which source do patients usually bleed?  

Pulmonary consultation agrees to perform bronchoscopy. There is no bleeding site identified in the upper airway. The trachea is normal. An endobronchial, friable mass is found in the right bronchus intermedius. Brushings and biopsies are taken and are read as being positive for squamous cell carcinoma. The bleeding remains at a minimal level.  

 

  1. What is the next step in the evaluation?   Pulmonary function testing is done; FEV1 is 1.2L, with no improvement after bronchodilators; FEV1/FVC ratio is 65%. There is no evidence of metastases to the bone, liver, or lymph nodes.  
  2. Is the patient a surgical candidate: why or why not?   Radiation therapy was instituted, with resolution of hemoptysis.  
  3. If bleeding had persisted, what other medical modalities might have been employed? 

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