A 65-year-old male with COPD, hypertension, hyperlipidemia, and a 40-pack-year smoking history presents to the ER with hemoptysis, what is the best initial approach?

History of Present Illness: 65-Year-Old Male with Hemoptysis

Chief Complaint

65-year-old male with COPD presents to the ER with hemoptysis.

History of Present Illness

Quantify the bleeding immediately to determine severity and guide management: Ask specifically about the volume of blood expectorated in the last 24 hours, the rate of bleeding, and whether it is streaky, clot-containing, or frank blood 1, 2. Morbidity and mortality correlate more closely with the rate of bleeding than total volume—a patient with rapid bleeding of 50 mL may be at higher risk than one with slow bleeding of 100 mL over 24 hours 3, 1.

Characterize the hemoptysis:

• Duration: When did it start? Is this the first episode or recurrent? 4, 5
• Volume: Scant (<5 mL), mild (5-200 mL), or massive (>240 mL or causing respiratory compromise)? 1, 2
• Appearance: Bright red, dark, frothy, mixed with sputum? 4, 5
• Associated symptoms: Fever, purulent sputum (suggests infection), dyspnea, chest pain, weight loss (malignancy concern)? 6

COPD-specific history:

• Current exercise tolerance and baseline functional status 6
• Recent exacerbation symptoms: increased dyspnea, change in sputum color or volume, wheezing 6
• Home oxygen use (LTOT) and nebulizer treatments 6
• Previous hospitalizations for COPD exacerbations in the past 5 years, including ICU admissions 6

Smoking history:

• 40 pack-year history raises significant concern for bronchogenic carcinoma, which causes cough and hemoptysis in >65% of cases at diagnosis 6. Heavy smokers with new onset cough, change in chronic cough characteristics, or hemoptysis should prompt consideration of lung cancer 6.

Pertinent Past Medical History

• COPD: Severity (FEV1 if known), frequency of exacerbations, baseline oxygen requirement 6
• Hypertension: Control status, end-organ damage 6
• Hyperlipidemia: Treatment and control 6
• Prior tuberculosis or fungal infections (aspergilloma causes 55% recurrence rate of hemoptysis) 1
• History of malignancy (raises possibility of metastatic disease to lung) 6
• Bronchiectasis (most common cause of hemoptysis in many series) 1
• Coagulopathy or bleeding disorders 5, 7

Medications

• Current COPD medications: Bronchodilators, inhaled corticosteroids, nebulizers 6
• Anticoagulants or antiplatelet agents (aspirin, warfarin, DOACs, clopidogrel)—these worsen bleeding 1, 5
• NSAIDs: Must be documented as they alter platelet function and significantly worsen hemoptysis 3, 1, 2
• Amiodarone or other cardiac medications for hypertension 6

Allergies

Document all drug allergies, particularly to antibiotics (as empiric antibiotics are indicated for hemoptysis ≥5 mL) 3, 1, 2.

Surgical History

• Prior thoracic surgery or lung resection 5, 7
• Recent procedures or biopsies that could cause bleeding 5

Recent Hospitalizations

• Admissions for COPD exacerbations, pneumonia, or respiratory infections in the past year 6
• ICU admissions for respiratory failure 6

Family History

• Lung cancer (increases risk in smokers) 6
• Bleeding disorders or coagulopathies 5
• Tuberculosis exposure 1, 5

Social History

• Tobacco use: 40 pack-years (90% of primary lung cancers are caused by smoking) 6
• Current smoking status and willingness to quit 6
• Occupational exposures: Asbestos, radon, other carcinogens 6
• Passive smoke exposure 6
• Living situation: Lives alone or with support? Quality of home environment and ability to manage at home? 6
• Alcohol or illicit drug use 4, 5

Review of Systems

Respiratory:

• Dyspnea at rest or with exertion, baseline exercise tolerance 6
• Chronic cough: productive vs. nonproductive, change in character 6
• Wheezing, chest tightness 6
• Sputum production: color (purulent suggests infection), volume 6

Constitutional:

• Fever, chills (infection) 6
• Weight loss, night sweats (malignancy, tuberculosis) 6, 5
• Fatigue 6

Cardiovascular:

• Chest pain, palpitations 6
• Peripheral edema (cor pulmonale) 6

Other:

• Confusion (hypercapnia, hypoxemia) 6
• Leg swelling or calf pain (pulmonary embolism consideration) 6

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Initial Clinical Assessment Priorities

On arrival, immediately assess:

• Vital signs: oxygen saturation, respiratory rate, heart rate, blood pressure 6
• Respiratory distress: use of accessory muscles, audible wheeze, tachypnea 6
• Signs of infection: fever, purulent sputum 6
• Cyanosis, confusion, peripheral edema 6

Oxygen therapy: Start with 24-28% Venturi mask or 1-2 L/min nasal cannulae targeting SpO2 88-92% until arterial blood gases are known 6. Check ABG within 60 minutes of starting oxygen 6.

Immediate labs: CBC, PT/aPTT, Clauss fibrinogen (not derived), type and cross-match, renal function, electrolytes 6, 1.

Imaging: Chest radiograph immediately to assess for pneumonia, mass, infiltrates, or aspiration 6, 3.

Antibiotic therapy: Start immediately for any hemoptysis ≥5 mL (amoxicillin or tetracycline first-line unless recently used) 6, 3, 1, 2.

Stop NSAIDs immediately for any hemoptysis ≥5 mL 3, 1, 2.