Mock Patient Script – Hemoptysis

By /

“There was blood in my cough…”

Want to review the clinical approach to hemoptysis before jumping into practice? Check out the full guide here:
👉 Symptom-based Approach – Hemoptysis

Hemoptysis—or coughing up blood—can be alarming for both patients and clinicians. From chronic bronchiectasis to life-threatening tuberculosis or simple upper airway bleeding, the spectrum is wide. In this article, we walk through 3 representative mock cases to refine your diagnostic reasoning, rule out critical conditions, and sharpen your questioning. Learn to tell real hemoptysis from mimickers, and navigate through OSCEs with confidence.

🩺 Case 1 – “I’ve been coughing up blood for weeks.”

🚪 Doorway Information

  • Age: 64
  • Gender: Female
  • Chief Complaint: Cough with blood-streaked sputum
  • Vital Signs: T 37.5°C / HR 84 / BP 128/74 / RR 18 / SpO₂ 96%

🗣️ Structured History

  • Opening: “I’ve been coughing for months, but now there’s blood in it.”
  • Shoreline: She started coughing 3 months ago, with occasional yellowish sputum. This morning she noticed bright red streaks in her phlegm.
  • Associated Symptoms: Denies fever, chest pain, or weight loss. Occasionally feels short of breath after climbing stairs.
  • Mood / Function / Appetite / Sleep: No fatigue or appetite loss. Sleeps well except for being woken by coughing at night.
  • Medical History / Medication: History of childhood asthma and frequent sinus infections. Not on regular medications.
  • Family & Social History (PAM HITS FOSS):
    • Previous/Past Medical History: Frequent bronchitis in her 40s
    • Allergies: None known
    • Medications: None
    • Hospitalizations: None
    • Injuries/Trauma/Surgery: None
    • Family History: Father had COPD, mother healthy
    • OBGYN: Two uncomplicated deliveries
    • Sexual History: Monogamous
    • Social History: Ex-smoker (10 pack-years, quit 15 years ago), no alcohol
  • Concerns & Questions: “Is this something serious like cancer?”

🩻 Physical Examination

  • Positive findings: Scattered coarse crackles over bilateral lower lungs
  • Negative findings: No wheezing, no clubbing, no cervical lymphadenopathy

🧠 Differential Diagnosis

  • Most likely diagnosis: Bronchiectasis
    • Supporting points: Chronic productive cough, past history of respiratory infections, coarse crackles, hemoptysis
    • Contradictory points: No recent fever or acute infectious signs
  • 2nd: Tuberculosis
    • Chronic cough and hemoptysis are compatible, but lacks systemic symptoms (fever, weight loss)
  • 3rd: Chronic bronchitis (COPD)
    • Ex-smoker and chronic cough fit, but less likely without airflow limitation or wheezing

💭 Clinical Reflection

This seems like a classic case of bronchiectasis. The chronicity, sputum quality, and lack of acute signs point toward a structural lung issue. A chest CT would be key for confirming the diagnosis and ruling out malignancy.

💡 Clinical Pearls

  • Don’t forget to ask about prior infections and sinus symptoms when evaluating chronic cough.
  • Hemoptysis in bronchiectasis is often due to fragile dilated vessels in the airways.
  • CT scan is essential for both diagnosis and localization of bronchiectasis.
  • Patients often underreport sputum color or frequency—probe gently.

❓ Challenging Questions

Q1: “Is this cancer?”
A: “It’s one of the possibilities, but there are many other more common causes like chronic infections or structural lung changes. We’ll start by doing a CT scan to get more information. Whatever it is, we’ll guide you step by step.”

Q2: “Will the bleeding get worse?”
A: “It’s unlikely to worsen suddenly in your case, but we’ll keep a close eye. If the bleeding increases or if you feel short of breath, seek care right away. For now, we’ll focus on understanding the cause and planning treatment.”

📝 SOAP Note

S: 64-year-old woman presents with several weeks of cough and recent onset of blood-streaked sputum. Denies weight loss, fever, or night sweats.

O: T 37.5°C, HR 84, BP 128/74, RR 18, SpO₂ 96%. Coarse crackles in lower lung fields. No clubbing or lymphadenopathy.

A:
# Chronic cough with intermittent hemoptysis
# Suspected bronchiectasis
# No systemic symptoms to suggest TB or malignancy

ddx): Bronchiectasis, tuberculosis, chronic bronchitis  
r/o): Malignancy (low risk but needs imaging), acute infection (no fever)

→ The chronic productive cough and localized lung sounds suggest bronchiectasis. Will order CT to confirm and monitor symptoms closely.

P:
- Chest CT (high-resolution)
- Sputum culture + AFB testing
- Pulmonary referral if structural damage confirmed
- Educate on signs of worsening bleeding

🩺 Case 2 – “I’ve lost weight… and now I’m coughing blood.”

🚪 Doorway Information

  • Age: 42
  • Gender: Male
  • Chief Complaint: Blood in cough
  • Vital Signs: T 37.8°C / HR 92 / BP 122/76 / RR 20 / SpO₂ 95%

🗣️ Structured History

  • Opening: “I’ve been feeling run-down lately… and this morning I coughed up blood.”
  • Shoreline: He reports 3 weeks of mild cough and fatigue, recently with weight loss. Today, he saw bright red streaks in his sputum.
  • Associated Symptoms: Occasional night sweats, low appetite, 4 kg weight loss over the past month. No chest pain or dyspnea.
  • Mood / Function / Appetite / Sleep: Fatigued easily, decreased appetite, wakes up sweating a few nights a week.
  • Medical History / Medication: Previously healthy, no medications.
  • Family & Social History (PAM HITS FOSS):
    • Previous/Past Medical History: Unremarkable
    • Allergies: NKDA
    • Medications: None
    • Hospitalizations: None
    • Injuries/Trauma/Surgery: Appendectomy as a teen
    • Family History: Father with diabetes, no TB
    • OBGYN: N/A
    • Sexual History: Married, monogamous
    • Social History: Works as a teacher, returned from a trip to Southeast Asia 2 months ago, no smoking or alcohol
  • Concerns & Questions: “Is this something infectious? Could I have passed it to my wife?”

🩻 Physical Examination

  • Positive findings: Slight crackles in the right upper lung field, mildly cachectic appearance
  • Negative findings: No lymphadenopathy, no clubbing, heart and abdomen unremarkable

🧠 Differential Diagnosis

  • Most likely diagnosis: Pulmonary Tuberculosis
    • Supporting points: Subacute cough, hemoptysis, weight loss, night sweats, recent travel to endemic area
    • Contradictory points: No known TB contact, afebrile
  • 2nd: Lung cancer (esp. adenocarcinoma)
    • Weight loss and hemoptysis fit, but less likely without smoking history or imaging findings
  • 3rd: Fungal infection (aspergillosis, etc.)
    • Immunocompetent patient with no chronic lung disease → less likely

💭 Clinical Reflection

Given his constitutional symptoms and travel history, TB should be ruled out urgently. Airborne precautions and early sputum testing are essential. Lung cancer should still be kept in mind until imaging is done.

💡 Clinical Pearls

  • Tuberculosis often presents subtly—ask about travel, fatigue, and appetite even if fever is absent.
  • Early imaging and sputum testing are key when TB is suspected.
  • Infectious hemoptysis requires both diagnostic and infection control measures.
  • Hemoptysis with weight loss → think TB or malignancy first.

❓ Challenging Questions

Q1: “Could I have passed this to my wife?”
A: “That’s a very valid concern. If this is an infection like TB, it can be transmitted through the air. We’ll arrange tests and give you guidance to protect your family while we wait for results.”

Q2: “Do I need to be hospitalized?”
A: “It depends on the test results and how you’re doing overall. If you’re stable, outpatient care might be possible with precautions. But if we confirm TB, we may need to involve public health to guide next steps safely.”

📝 SOAP Note

S: 42-year-old male with 3 weeks of cough, fatigue, weight loss, and night sweats. New onset hemoptysis today. Returned from Southeast Asia 2 months ago.

O: T 37.8°C, HR 92, RR 20, SpO₂ 95%. Mild crackles in RUL. Appears thin. No lymphadenopathy.

A:
# Subacute hemoptysis with weight loss
# Suspected pulmonary tuberculosis
# Must rule out malignancy and other infections

ddx): TB, lung cancer, fungal infection  
r/o): Bronchiectasis (no prior infections), PE (no acute dyspnea or risk factors)

→ Given the symptoms and travel history, TB is high on the list. Will initiate sputum testing and chest imaging with airborne precautions.

P:
- Chest X-ray + CT (if CXR unclear)
- 3x sputum AFB + culture
- HIV test and CBC, CRP
- Notify public health if TB confirmed
- Counsel patient and family re: transmission precautions

🩺 Case 3 – “My throat feels fine… but there’s blood in my saliva.”

🚪 Doorway Information

  • Age: 29
  • Gender: Male
  • Chief Complaint: Intermittent blood when spitting
  • Vital Signs: T 36.8°C / HR 72 / BP 118/70 / RR 16 / SpO₂ 98%

🗣️ Structured History

  • Opening: “Sometimes when I clear my throat, I see blood in the sink.”
  • Shoreline: He noticed blood-streaked saliva twice this week, especially in the morning. No cough, no sputum, no fever.
  • Associated Symptoms: Mild throat irritation. No weight loss, no night sweats, no dyspnea, no epistaxis.
  • Mood / Function / Appetite / Sleep: Feels well otherwise. Normal energy, appetite, and sleep.
  • Medical History / Medication: History of allergic rhinitis, uses nasal steroid spray seasonally. No daily meds.
  • Family & Social History (PAM HITS FOSS):
    • Previous/Past Medical History: Allergies, tonsil stones as teen
    • Allergies: Pollen (seasonal)
    • Medications: Occasionally uses intranasal corticosteroids
    • Hospitalizations: None
    • Injuries/Trauma/Surgery: Wisdom teeth extraction
    • Family History: Non-contributory
    • OBGYN: N/A
    • Sexual History: Active, monogamous
    • Social History: No smoking, drinks socially
  • Concerns & Questions: “Do I need a scan or something? Could this be coming from my lungs?”

🩻 Physical Examination

  • Positive findings: Mild postnasal drip; small ulceration on posterior oropharynx
  • Negative findings: Clear lungs; no cough, no lymphadenopathy, no oral lesions or gingival bleeding

🧠 Differential Diagnosis

  • Most likely diagnosis: Pseudophempotysis (upper airway bleeding)
    • Supporting points: No cough, no sputum, normal lungs, visible oropharyngeal lesion
    • Contradictory points: Slight worry due to blood in saliva, but no respiratory symptoms
  • 2nd: Minor gingival or oral ulcer bleeding
    • Could explain intermittent bloody saliva, especially in the morning
  • 3rd: Posterior epistaxis
    • Less likely without nasal symptoms or crusting, but worth asking about sneezing or nosebleeds

💭 Clinical Reflection

This is not true hemoptysis. It’s important to avoid over-testing when the bleeding clearly originates from the upper airway or oral cavity. A thorough ENT exam often saves unnecessary imaging.

💡 Clinical Pearls

  • “Hemoptysis” must involve the lower respiratory tract—no cough = look elsewhere.
  • Early morning blood-tinged saliva is often from oral or nasopharyngeal sources.
  • Always examine the oropharynx and ask about nasal symptoms.
  • Patients may confuse postnasal drip or GERD with lung bleeding—clarify symptoms clearly.

❓ Challenging Questions

Q1: “Should I get a CT scan?”
A: “That’s a common question. Since there’s no cough, no sputum, and your lungs sound completely normal, this likely isn’t coming from your lungs. We’ll monitor and treat the local cause first—and if it doesn’t improve, we can reassess.”

Q2: “What if it happens again tomorrow?”
A: “If it recurs but stays minor and you’re feeling well, it’s probably not dangerous. We’ll give you care instructions and ask you to return if it worsens or becomes more frequent. It’s always better to be cautious, and we’ll stay on top of it.”

📝 SOAP Note

S: 29-year-old male with intermittent blood-streaked saliva for 2 days. No cough, no sputum, no respiratory symptoms. Mild throat irritation.

O: T 36.8°C, HR 72, BP 118/70, RR 16, SpO₂ 98%. Normal lung sounds. Small oropharyngeal ulcer noted. No gingival bleeding.

A:
# Pseudophempotysis – suspected upper airway source
# No signs of lower respiratory involvement
# Monitor for recurrence or worsening

ddx): Upper airway ulcer, gingival bleeding, posterior epistaxis  
r/o): Hemoptysis (no cough), pneumonia (no fever or ausc. findings), malignancy (young, no risk factors)

→ Upper airway exam confirms likely local cause. No immediate need for imaging. Will monitor and educate patient.

P:
- Topical saline gargles
- ENT referral if no improvement in 1 week
- Reassurance and red flag education
- Avoid unnecessary imaging unless new symptoms arise

🧭 Summary & Differentials

Coughing up blood, or hemoptysis, may range from benign causes like post-infectious inflammation to serious illnesses like tuberculosis or lung cancer. In these 3 mock cases, we practiced evaluating both typical and deceptive presentations, sharpening our diagnostic process by relying on history, auscultation, and imaging only when appropriate. It is crucial to distinguish true hemoptysis from mimickers and remain vigilant for red flags.

🧠 VITAMIN CDE-based Differentials for Hemoptysis

  • V – Vascular: Pulmonary embolism, AV malformation, mitral stenosis (pulmonary congestion)
  • I – Infectious: Tuberculosis, pneumonia, lung abscess, aspergilloma
  • T – Trauma: Post-biopsy, post-bronchoscopy, chest injury
  • A – Autoimmune: Granulomatosis with polyangiitis, Goodpasture’s syndrome, SLE
  • M – Metabolic: Uremia-induced alveolar hemorrhage (rare)
  • I – Idiopathic: Cryptogenic hemoptysis
  • N – Neoplastic: Lung cancer (esp. squamous cell), carcinoid tumors
  • C – Congenital: Bronchiectasis (e.g., cystic fibrosis), pulmonary AVMs
  • D – Drugs: Anticoagulants (warfarin, DOACs), cocaine inhalation
  • E – Endocrine: Not typically relevant for hemoptysis

🔗 Related Articles

📚 Recommended Resources

  • First Aid for the USMLE Step 2 CS – For clinical encounter frameworks
  • DxSchema（by 診断戦略） – For symptom-based differential organization
  • Tierney’s Diagnostic Strategy – Classic book for internal medicine reasoning
  • Oshimi Blog（押味先生） – Great Japanese resource for clinical training

Leave a Comment

Your email address will not be published. Required fields are marked *

Scroll to Top