A 34-year-old male immigrant from Mexico is brought to the emergency department after coughing up foamy sputum with a "significant" amount of bright-red blood. His clothes are stained red, but he is not currently having any coughing spells. He has no recent trauma and no other medical problems. He takes no medications. His blood pressure is 112/63 mm Hg, pulse is 97/min, and respirations are 16/min. Pulse oximetry shows 95% on room air. The patient is mildly agitated. Breath sounds are audible bilaterally with some expiratory wheezing on the right side. Intravenous fluids are initiated, and the patient is placed on supplemental oxygen. Portable chest x-ray shows a dense opacity in the right upper lobe.
Which of the following is the best initial step in management of this patient?

Question

A 34-year-old male immigrant from Mexico is brought to the emergency department after coughing up foamy sputum with a "significant" amount of bright-red blood.  His clothes are stained red, but he is not currently having any coughing spells.  He has no recent trauma and no other medical problems.  He takes no medications.  His blood pressure is 112/63 mm Hg, pulse is 97/min, and respirations are 16/min.  Pulse oximetry shows 95% on room air.  The patient is mildly agitated.  Breath sounds are audible bilaterally with some expiratory wheezing on the right side.  Intravenous fluids are initiated, and the patient is placed on supplemental oxygen.  Portable chest x-ray shows a dense opacity in the right upper lobe. 
Which of the following is the best initial step in management of this patient?

Quizplus · Accepted Answer

Although there are several possible etiologies for the presence of hemoptysis, this patient's presentation (coming from an endemic area, symptoms, and upper-lobe involvement) is suggestive of pulmonary tuberculosis. Tuberculosis typically has radiographic abnormalities (eg, patchy or nodular opacity, multiple nodules, cavity) involving the apical-posterior segments of the upper lobes of the lungs. This patient is now stable, and the next step is to place him in complete respiratory isolation to avoid further exposure to healthcare professionals and other individuals. Respiratory isolation should be continued until the diagnosis of tuberculosis can be confirmed or refuted by additional testing (eg, acid-fast bacilli smear and culture). hemoptysis (Choice A) Broad-spectrum antibiotics are indicated for the treatment of pneumonia, but this patient's abnormal chest x-ray and presentation are more concerning for tuberculosis. The most appropriate next step should be to place him in respiratory isolation. (Choice B) Bronchoscopy should be performed to directly visualize and control the site of bleeding in patients with massive hemoptysis (>600 mL/day or 100 mL/hr). This patient is stable, and sputum analysis would be the next appropriate step. (Choice C) Chest CT scan is useful in subsequent diagnostic workup and therapeutic planning for evaluation of other possible causes. However, this patient first needs respiratory isolation and sputum analysis to confirm the diagnosis of pulmonary tuberculosis. (Choice D) Endotracheal intubation should be performed to protect the airway in patients with hemoptysis who are hemodynamically unstable or have poor gas exchange, severe dyspnea, or massive hemoptysis. It is not indicated in this patient at this time. Educational objective: Patients with hemoptysis and high clinical suspicion for pulmonary tuberculosis should be placed in respiratory isolation to prevent the spread of infection before further diagnostic evaluation and treatment. References: Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. (http://www.ncbi.nlm.nih.gov/pubmed/2742442) Massive hemoptysis. Assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/8200191)

A 34-Year-Old Male Immigrant from Mexico Is Brought to the Emergency