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A 67-Year-Old Man with Massive Hemoptysis

Case Editor - Judd Flesch

Reviewed By Critical Care Assembly

Submitted by

Timothy R. Watkins, MD

Acting Instructor of Medicine

Division of Pulmonary and Critical Care Medicine

University of Washington, Harborview Medical Center

Seattle, WA

Colin R. Cooke, MD, MSc

Senior Fellow

Division of Pulmonary and Critical Care Medicine

University of Washington, Harborview Medical Center

Seattle, WA

Submit your comments to the author(s).


A 67-year-old man who was recently diagnosed with pulmonary tuberculosis and treated with four-drug antituberculous directly observed therapy for the last month presented to the emergency department with hemoptysis.   The patient stated he had small amounts of blood-streaked sputum for the past 2 weeks, but noted that immediately prior to coming to the emergency department he had coughed up approximately “a cup” of bright red blood.  While still in the emergency department, he had a witnessed episode of large volume hemoptysis, estimated to be greater than 250 cc of fresh blood. 

The patient’s past medical history was unremarkable with the exception of longstanding tobacco abuse.  Other than his recent antituberculous therapy he took no regular medications.  He did not regularly use aspirin or other NSAIDs.  He had no history of rash, kidney disease, hematuria, or known autoimmune disease.  Prior to the episodes described above, he had no history of pneumonia or hemoptysis.

The patient smoked one pack of cigarettes per day for the past 45 years.  He did not use alcohol or other recreational drugs.   He emigrated from Ethiopia to the United States 10 years earlier.  The patient was single, living with his brother’s family.   He worked as a carpenter until 2 to 3 months earlier when he became ill.

Physical Exam

The patient appeared uncomfortable and in distress.  During the exam he continued to cough up small amounts of bright red blood. Vital signs were notable for a blood pressure of 101/60 mmHg, a heart rate of 113 beats per minute, a respiratory rate of 25-32 breaths per minute, and an oxygen saturation of 93% on a 100% oxygen via high-flow face mask.  The head and neck exam was notable for the presence of blood in the oropharynx and clear nares.  The cardiac exam demonstrated tachycardia, a normal S1 and S2, and no murmur, gallop or rub.  The lungs were notable for the presence of low-pitched rhonchi, right greater than left.  The abdomen was benign without organomegally.  The patient’s extremities were slightly cool, without cyanosis, clubbing or edema.  The skin was clear without a rash.  Labs were drawn at time of admission, prior to the episode of hemoptysis episode in the emergency department.


White blood cell count 11,000/mm3 with a slight left shift present
Hematocrit 12%
Platelet count was 378,000/mm3
BUN 49 mg/dl, serum creatinine was 1.1 mg/dl
Alkaline phosphatase 124mg/dl
Total bilirubin 1.4mg/dl
AST 50 IU/L, ALT 29 IU/L
The patient’s electrolytes and serum glucose were within normal limits.
An INR and PTT were within normal limits.
A urinalysis showed an elevated specific gravity and the presence of hyaline casts.


Fig. 1: Chest Radiograph Taken on Admission

Fig. 2: CT Pulmonary Angiogram (Soft Tissue Window)

Fig. 3: CT Pulmonary Angiogram (Coronal Reconstruction)

Fig. 4: Pulmonary Agiogram

Question 1

The most appropriate NEXT step in the management of this patient is:


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