A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis. For the past several days, he has had increasing cough with greenish-yellow sputum. He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit. The patient has mild dyspnea but no fever or chest pain. His other medical problems are peripheral vascular disease and osteoarthritis. His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium. He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally. The patient had a screening CT scan 2 years ago that was negative for lung mass. His father died of lung cancer. Blood pressure is 140/95 mm Hg and heart rate is 100/min. The patient's pulse oximetry shows 95% on room air. Lung auscultation reveals bilateral expiratory wheezing.
Which of the following is the best initial step in management of this patient?

Question

A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient's pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing. 
Which of the following is the best initial step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c07e_f994_8f63_877e199f3bb1_MD0005_00 This patient's worsening cough with sputum production suggests acute bronchitis causing an exacerbation of underlying chronic obstructive pulmonary disease (COPD). Airway inflammation in acute bronchitis can cause erosion of the superficial vessels, leading to hemoptysis, which is usually scant or small in volume. Plain chest radiograph remains the initial test of choice as it may identify the site and cause of bleeding (eg, cavitary lesion, lung mass, or stigmata of mitral stenosis) in over one-third of patients. In combination with the clinical picture, a chest radiograph may also help direct further management (bronchoscopy versus CT scan). mitral stenosis (Choice A) Further evaluation, such as fiberoptic bronchoscopy to reveal endobronchial carcinoma, should be based on initial chest x-ray findings and the degree of clinical suspicion of a specific cause. (Choice C) Patients at high risk for lung cancer should have a CT scan to rule out malignancy. This patient's acute presentation and absence of alarming symptoms (eg, chronic cough, weight loss) argue against development of malignancy since his CT scan 2 years ago. Chest CT should be considered only if the hemoptysis persists despite treatment of COPD exacerbation. (Choices D and E) Sputum cytology and culture are of little significance in demonstrating the cause of hemoptysis. They also have little diagnostic significance in patients with COPD. Educational objective: Chest x-ray abnormalities may suggest a variety of specific causes in patients with hemoptysis, including malignancy, focal infection (eg, pulmonary tuberculosis), or heart disease (eg, mitral disease). References: ACR appropriateness criteria® hemoptysis. (http://www.ncbi.nlm.nih.gov/pubmed/24717602)

A 60-Year-Old Man with a History of Chronic Obstructive Pulmonary