Presented by Daniel Seitz, MD
CC: “I’m coughing up blood”.
HPI: A 44-year-old man presents to the Emergency Department complaining of coughing up blood for two days. The patient states that two months ago he began experiencing progressively worsening cough and fatigue. The cough was initially non-productive, but for the past month he’s been coughing up thick yellow sputum. One week ago he noticed that his sputum was intermittently blood streaked, and yesterday he coughed up gross blood. Over the last 24hrs the patient reports coughing up a cup and a half of gross blood. He describes the blood as bright red, frothy and devoid of food particles. He also reports a history of weight loss, approximately 20lbs in the last 6 months. The patient occasionally has fevers in the afternoon, and reports night sweats over the past three weeks. The patient states that he experiences a diffuse achy pain on deep inhalation and with cough. He denies any shortness of breath or difficulty breathing.
ROS: Negative except for as mentioned in the HPI.
PMH: Hypertension which he’s treating with diet and exercise.
Allergies: No known drug allergies.
FH: Hypertension, heart disease, and diabetes.
SH: The patient smokes 1 pack per day, has smoked for ten years, occasionally drinks alcohol, and denies any illicit drug use. The patient lives alone and works as an actuary. He was born in China and immigrated to the United States as a teenager.
VITAL SIGNS: BP 92/55, P 109, R 21, T 38.4, SpO2 95% on room air.
GENERAL: Patient is sitting comfortably in his stretcher and is in no apparent acute distress.
HEAD: Head is atraumatic, normocephalic, and no tenderness to palpation.
EYES: Mild conjunctival pallor. Pupils are 4 mm bilaterally, are equally round and reactive to light and accomodation. No nystagmus. No conjunctival injection, but mild conjuctival pallor. No scleral icterus
EARS: Tympanic membranes are normal.
NOSE: No nasal drainage, no blood in nares, no swollen turbinates.
MOUTH: Dried blood around the patient’s mouth. Moist mucous membranes, no tonsillar enlargment or exudates, no intraoral lesions.
NECK: Supple without lymphadenolpathy. There is no nuchal rigidity, no tenderness to palpation, no carotid bruits, trachea is midline.
CARDIOVASCULAR: S1, S2, tachychardic rate with normal rhythm. No murmurs, rubs or gallops. Peripheral pulses are present , 2+, and symmetric in all four extremities.
RESPIRATORY: Good air entry bilateral. Diffuse post-tussive rales, distant breath sounds heard over the lung apices .
GASTROINTESTINAL: Abdomen soft, non-tender, non-distended, no tenderness to palpation, no appreciable organomegaly. Bowel sounds present in all quadrants.
MUSCULOSKELETAL: Patient is mildly cachexic. Strength 5/5 proximally and distally in all extremities.
SKIN: No rashes, lesions or ulcerations. Increased pallor.
NEUROLOGIC: Patient is awake, alert and oriented to person, place and time. Face is symmetrical. Sensation is equal and intact throughout. The patient walks with a normal gait and performs finger to nose examination without difficulty.
Course in the ED: While waiting to be seen in the module, the patient expectorates 700 mLs of gross blood. The patient is rushed to resuscitation; where he’s placed on a monitor and two large bore peripheral IVs are placed. A stat portable chest x-ray is obtained which shows a cavitary lesion at the apex of the patient’s left lung. The patient’s vital signs in resuscitation are as follows: T: 38.6 HR: 112 RR: 25 BP: 81/50 O2Sat: 87% on non-rebreather.
What is the patient’s most likely diagnosis?
a) Lung cancer
Which of the following characteristics indicates hematemesis over hemoptysis?
a) Alkaline pH
b) Dark color
c) Frothy appearance
d) Presence of macrophages
What is the best course of management in this patient?
a) Emergent angiography
b) Flexible Bronchoscopy
c) Intubation of the right main stem bronchus, and place patient in left lateral decubitus position
d) Rigid Bronchoscopy
e) Rush the patient to the operating room for emergent thoracotomy
What vessel is most likely responsible for this patient’s massive hemoptysis?
b) Bronchial artery
c) Inominate artery
c) Pulmonary artery
d) Tracheobronchial capillaries
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