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Clinical Case 2
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Objectives:

  • Perform an appropriate evaluation on a patient with hemoptysis
  • Recognize the major causes of hemoptysis
  • Diagnose Wegener’s granulomatosis
  • Identify massive hemoptysis



1

You see a 38-year-old female in follow-up for a recent episode of sinusitis. The whole illness has been present for about 6 weeks and has failed 2 weeks of appropriate antibiotics. She continues to have intermittent nosebleeds, fatigue, arthralgias, low-grade fevers, and night sweats. Two new complaints have surfaced: she has a cough productive of white sputum and she occasionally expectorates quarter-sized clots of blood. She denies chest pain, dyspnea, tobacco use, or any history of cardiac or pulmonary disease.

On examination, she appears in no distress. She is afebrile, and her respiratory rate is 16, blood pressure 120/74, and pulse 92. Her oxygen saturation is 98% on room air. There is dried blood in the nares, but the oropharynx is clear. Cardiac and pulmonary exams are unremarkable.

Which initial test is most appropriate?

A)Chest x-ray.
B)Sputum cytologic analysis.
C)Bronchoscopy.
D)Chest CT.
E)CBC.
2

Which of the following is NOT a radiographic finding of Wegener’s granulomatosis?
A)Nodules that may be cavitary.
B)Alveolar opacification.
C)Pleural opacities.
D)Widened mediastinum from adenopathy or hemorrhage.
3

The diagnostic evaluation is in process. Laboratory tests are pending, and a chest CT is scheduled. You plan to follow up with the patient next week, and you have arranged for a pulmonologist to see her. When you are next on call, the physician covering the emergency department calls you to admit her for “massive hemoptysis.” When you arrive, the patient looks comfortable and has normal vital signs. She begins a fit of coughing, expectorating several ounces of bright red blood. Her systolic blood pressure falls to 80 mm Hg. Her respiratory rate is 40, and appears distressed. This does not improve after 5 minutes of observation, and her O2 saturation is now 83%.

What is your first action in this situation?

A)Arrange emergent bronchoscopy.
B)Transfuse 2 units of blood.
C)Perform endotracheal intubation.
D)Provide bolus IV normal saline.
E)Call for emergent surgical evaluation.
4

The patient stabilizes and you would like to start treatment for this patient’s Wegener's.

Your drug regimen may include all of the following EXCEPT:

A)Cyclophosphamide.
B)Corticosteroids.
C)Methotrexate.
D)Sulfasalazine.







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