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Topic
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Questions
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Snapshot
  • A 58-year-old man presents to an urgent care clinical after coughing up blood and experiencing shortness of breath. The patient reports that he has been coughing recently and decided to cut back on his cigarette use. He notes a 25-lb unintentional weight loss over the course of 6 months, along with night sweats and generalized malaise. On physical exam, the patient has blood in his sputum and no notable source of bleeding in his oropharynx. A chest radiograph is performed, which demonstrates a bronchial mass. (Lung cancer)
Introduction
  • Definition
    • expectoration of blood from the lower respiratory tract
      • hemoptysis is said to be massive when there is ≥ 500 mL of blood over 24 hours or ≥ 100 mL/hour 
  • Etiology
    • airway diseases
      • bronchitis
      • bronchogenic carcinoma
      • bronchiectasis
    • pulmonary parenchymal diseases
      • tuberculosis
      • abscess
    • rheumatic diseases
      • amyloid
      • anti-glomerular basement membrane disease (Goodpasture disease) 
        • treat with steroids, plasmapheresis, and cyclophosphamide for acute flares 
      • granulomatosis with polyangiitis (Wegener disease) and other vasculitides
      • systemic lupus erythematosus
    • pulmonary vascular diseases
      • pulmonary embolism 
      • pulmonary arteriovenous malformation
      • heart failure
    • coagulation disorders
      • disseminated intravascular coagulation
      • anticoagulant and antiplatelet medications
    • iatrogenic
      • bronchoscopy
    • other
      • cocaine use
      • catamenial hemoptysis due to thoracic endometriosis
  • Pathoanatomy
    • blood comes from 2 sources
      • pulmonary arteries
      • bronchial arteries (most common source of massive hemoptysis)
Presentation
  • Symptoms
    • hemoptysis
  • Physical exam
    • blood can range from a streak of blood to gross blood
Imaging
  • Chest radiograph
    • indication
      • initial imaging study in the evaluation of hemoptysis
  • CT of the chest
    • indication
      • considered in patients with an abnormal chest radiograph, risk factors for malignancy, or recurrent hemoptysis
        • risk factors for malignancy include
          • > 40 years of age
          • substantial smoking history
  • Bronchoscopy
    • indication
      • confirms hemoptysis and localizes the bleeding
Studies
  • Diagnostic approach
    • based on an extensive history and physical and chest imaging
      • it is important to differentiate hemoptysis from hematemesis or from the upper respiratory and gastrointestinal tract
    • laboratory testing is dependent on clinical suspicion
      • e.g., a patient comes from a tuberculosis-endemic region presenting with hemoptysis should get sputum acid-fast bacilli testing
Differential
  • Hematemesis
    • differentiating factors
      • source of bleeding is noted on endoscopy
Treatment
  • Conservative
    • patient positioning
      • indication
        • in cases of severe hemoptysis
        • position patient on the side of the involved lung and intubate the normal lung if necessary
          • e.g., if the source of the bleed is from the right lung, position the patient on the right side
  • Procedural
    • therapeutic bronchoscopy
      • indication
        • recommended in life-threatening cases
    • bronchovascular artery embolization
      • indication
        • first-line for massive, recurrent, or malignant hemoptysis
    • emergency thoracotomy 
      • indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy)
Complications
  • Asphyxiation
  • Exsanguination

 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PL.16.4691) A 27-year-old male presents to clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrates interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab). What is the most likely diagnosis? Review Topic | Tested Concept

QID: 107625
1

Systemic lupus erythematous (SLE)

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(0/10)

2

Granulomatosis with polyangiitis (Wegner's)

10%

(1/10)

3

Microscopic polyangiitis

0%

(0/10)

4

Churg-Strauss syndrome

0%

(0/10)

5

Goodpasture disease

90%

(9/10)

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(M2.PL.14.31) A 60-year-old man presents to the emergency department with pleuritic chest pain. He recently returned from a vacation in Germany and noticed he felt short of breath and had chest pain the following morning. The patient is generally healthy but did have surgery on his ankle 3 weeks ago and has been less ambulatory. His temperature is 99.0°F (37.2°C), blood pressure is 137/88 mm Hg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 96% on room air. Physical exam is notable for a warm and swollen lower extremity. The physician has high clinical suspicion for pleuritis given a recent cough the patient experienced. Which of the following findings would warrant further workup with a CT angiogram?
Review Topic | Tested Concept

QID: 103521
1

Bilateral wheezing

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(0/10)

2

Decreased breath sounds over area of the lung

50%

(5/10)

3

Hemoptysis

50%

(5/10)

4

Increased breath sounds over area of the lung

0%

(0/10)

5

Green sputum

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(M2.RH.14.50) A 47-year-old man presents with hemoptysis, diffuse muscle pain, and shortness of breath. He has had these symptoms before but did not seek treatment. His past medical history is not known as he is not typically followed by a doctor and is homeless. His temperature is 99.0°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 89/min, respirations are 22/min, and oxygen saturation is 90% on room air. Physical examination is notable for crackles noted in the bases of the lungs bilaterally. Labs values are ordered as seen below.

Serum:
Na+: 140 mEq/L
Cl-: 103 mEq/L
K+: 5.8 mEq/L
HCO3-: 21 mEq/L
BUN: 33 mg/dL
Glucose: 129 mg/dL
Creatinine: 2.6 mg/dL

Urine:
Color: Amber
Protein: Positive
Blood: Positive

Which of the following is the most appropriate treatment for this patient?
Review Topic | Tested Concept

QID: 105867
1

Methylprednisolone

32%

(12/37)

2

Methylprednisolone and cyclophosphamide

41%

(15/37)

3

Methylprednislone, IVIG, and cyclophosphamide

11%

(4/37)

4

Methylprednisolone, plasmapheresis, and cyclophosphamide

5%

(2/37)

5

Plasmapheresis and cyclophosphamide

3%

(1/37)

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