A 53-year-old man comes to the office with 2 episodes of hemoptysis over the past week. He has a 2-year history of morning cough producing approximately 1 tablespoon of white sputum. During the last week, his morning cough was accompanied by a small amount of blood on 2 occasions. He has no dyspnea, fever, chest pain, or weight loss. The patient has smoked for 30 years but has tried to cut down recently. He works in construction. His only medication is ranitidine for occasional heartburn. Which of the following is the most likely cause of this patient's hemoptysis?

Question

A 53-year-old man comes to the office with 2 episodes of hemoptysis over the past week.  He has a 2-year history of morning cough producing approximately 1 tablespoon of white sputum.  During the last week, his morning cough was accompanied by a small amount of blood on 2 occasions.  He has no dyspnea, fever, chest pain, or weight loss.  The patient has smoked for 30 years but has tried to cut down recently.  He works in construction.  His only medication is ranitidine for occasional heartburn.  Which of the following is the most likely cause of this patient's hemoptysis?

Quizplus · Accepted Answer

11ec25c8_d1fa_bc4f_bc81_b16e758dab4b_MD0003_00 This patient's presentation - longstanding smoking and chronic productive cough with recent hemoptysis - is consistent with chronic bronchitis. Hemoptysis is defined as any expectoration of blood originating from the lower respiratory tract, with a wide spectrum from minimal blood streaking in sputum to the presence of frank blood and/or clots. There are many causes of hemoptysis, but pulmonary airway disease (eg, chronic bronchitis, bronchogenic carcinoma, bronchiectasis) ranks as the most common. Chronic bronchitis is defined as a chronic productive cough for >3 months in 2 successive years, and cigarette smoking is the leading cause. This patient would also require chest imaging to rule out malignancy. > (Choice A) Bronchiectasis refers to irreversible dilation and destruction of bronchi, resulting in chronic cough and inadequate mucus clearance. Compared with chronic bronchitis, bronchiectasis is more likely associated with a history of recurrent respiratory tract infections and chronic cough with daily production of copious mucopurulent sputum. (Choice C) Patients with lung abscesses are usually ill with fever, chills, and purulent expectoration. (Choice D) Mitral stenosis causes hemoptysis by producing acute pulmonary edema, which is unlikely in the absence of dyspnea. (Choice E) Pulmonary emboli can present with hemoptysis. However, this patient's symptoms are more chronic in nature, and he has no other symptoms or signs (eg, sudden-onset pleuritic chest pain, dyspnea) suggestive of pulmonary embolism. (Choice F) In rare instances, severe thrombocytopenia can present with hemoptysis. However, the most common initial presentation is cutaneous bleeding (eg, petechiae, purpura). (Choice G) Tuberculosis often presents with chronic cough and hemoptysis. Patients usually have the associated symptoms of low-grade fever and weight loss. In developed countries, chronic bronchitis is a more frequent cause of hemoptysis than tuberculosis. Educational objective: Pulmonary airway disease (eg, chronic bronchitis, bronchogenic carcinoma, bronchiectasis) is the most common cause of hemoptysis in adults. Chronic bronchitis is defined as a chronic productive cough for >3 months in 2 successive years, with cigarette smoking as the leading cause. > References: Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. (http://www.ncbi.nlm.nih.gov/pubmed/2742442)

A 53-Year-Old Man Comes to the Office with 2 Episodes