[Answered]: A 54-year-old man with 40-pack-year smoking history…

A 54-year-old man with 40-pack-year smoking history presented in the emergency department with chest pain. The pain was sudden in onset, persistent with mid sternum location and radiating to his neck, upper arms and back. He had a productive cough with increasing amount of blood tinged sputum and intermittent wheezing over 3 weeks. He also had a pleuritic chest pain with a cough. The patient did develop progressive shortness of breath with hemoptysis and noticed to have night sweats. However, there were no other infectious symptoms including fever, chills or recent weight loss. He denied illicit drug usage, tuberculosis exposure, and recent travel or incarceration. He reported negative HIV and purified protein derivative (PPD) skin testing. His medical history also includes hypertension, peripheral vascular disease and chronic kidney disease. On examination in the emergency department, the patient was afebrile though tachycardiac. Heart rate was 107 beats per minute, blood pressure 119/68 mm Hg and the respiratory rate was increased to 24 breaths per minute with the oxygen saturation of 96% while breathing ambient air. Auscultation of the chest revealed diminished breath sounds at the right lung with mild expiratory wheezing. The remainder of the physical examination was unremarkable. Chest radiograph showed right upper lobe bullae. Additional laboratory workup revealed mild leucocytosis with white blood cell count of 14 400/mu L, mild anemia with hemoglobin of 11.9 g/dL but normal platelet count 268times 103/mu L. Coagulation profile including prothrombin time (PT) and partial thromboplastin time (PTT) was within normal limits. Serial troponins were in normal range and the ECG did not reveal acute ST-T wave changes. Infectious workup including sputum culture and respiratory viral panel was requested. Due to worsening hemoptysis and persistent chest pain, CT of the chest with contrast was performed.