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A 17-year-old high school soccer player reports an episode of hemoptysis. He describes a cough that has lasted for approximately 1 week. Until yesterday the cough had been productive of scant amounts of off-white sputum. Yesterday during soccer practice, the patient expectorated a teaspoonful (5 mL) of bright red blood. He left practice and rested for the remainder of the day. The sputum had streaks of blood in it late in the day and none this morning. The patient reports having a “bad cold” 2 weeks ago and has a residual cough. He denies illicit drug use or homosexual encounters. He has a history of seasonal allergies and no asthma. He has never smoked cigarettes. He denies prior hemoptysis, shortness of breath, fever, chest pain, recent surgery, prolonged automobile or plane travel, exposure to tuberculosis, history of rheumatic fever or heart murmur, known renal disease, bleeding elsewhere, or a family history of lung or bleeding disorder. The patient does not have a fever and the results of a cardiopulmonary examination are normal.
The first diagnostic test in the assessment of hemoptysis for this patient is:
(A) Coagulation studies (prothrombin time, partial thromboplastin time, and platelet count)
(B) Chest radiograph
© Blood test for antinuclear cytoplasmic antibodies
(D) Bronchoscopy
(E) Urinalysis
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Posts: 3,675,937
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Posts: 3,675,937
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Posts: 3,675,937
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Why not A, blood test should be first, then imaging.
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in a case of bronchitis.. blood tests are usually not helpful.. but to rule out other etiology like pneumonia and infection.. we need to do CXR. ANS B.
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ANSWER IS B
Evaluation of hemoptysis, even if it consists of only minor and transient blood streaking of sputum, should begin with a chest radiograph. An abnormality on the chest radiograph, if clinically relevant, may guide further evaluation of hemoptysis. Although this young soccer player has a benign-sounding history of hemoptysis in the setting of a respiratory tract infection, a chest radiograph may show an abnormality not suspected from the results of the physical examination alone. Examples are an endobronchial mass with postobstructive atelectasis suggestive of a carcinoid tumor or a small infiltrate in the posterior segment of the upper lobe that suggests tuberculosis. Findings such as these direct subsequent evaluation, such as fiberoptic bronchoscopy in the former example and tuberculin skin test and sputum culture for acid-fast bacilli in the latter example.
Patients with massive hemoptysis or with bleeding from additional sites besides the lungs need blood studies for a platelet or coagulation abnormality. The antinuclear cytoplasmic antibody test has proved useful in the care of patients with evidence of systemic vasculitis, especially Wegener’s granulomatosis. This patient has no findings indicative of involvement of more than one system, such as skin, sinuses, kidneys, joints, or peripheral nerves, that suggest the presence of systemic vasculitis.
If this patient has normal chest radiographic findings and no recurrence of hemoptysis, it is not necessary to pursue immediate bronchoscopy. The main benefit of bronchoscopy is to exclude an endobronchial neoplasm not visible on a chest radiograph. A young (younger than 40 years) nonsmoker with hemoptysis of brief duration (< 1 week) is at low risk of endobronchial tumor and in most instances can be observed for a recurrence of hemoptysis without immediate bronchoscopy. Urinalysis may be helpful when a pulmonary-renal hemorrhage syndrome is suspected. However, with pulmonary-renal hemorrhage syndromes, one anticipates an abnormal chest radiograph indicative of diffuse alveolar hemorrhage (diffuse airspace disease) or multiple pulmonary nodules (as is found in Wegener’s granulomatosis).
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The patient reports having a “bad cold” 2 weeks ago and has a residual cough....
Less than 40 yrs, less than 1 wk hemoptysis, ..low risk of endobrachial tumor...no need bronchoscopy stat...
Good one, thanks
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