Initial Consult - Respirology

Thank you for your referral. Please find below the summary of my evaluation. Feel free to contact me for any questions or coordination of care.

History of Present Illness:
Mai Nguyen reports three episodes of hemoptysis over the past six months. The first episode occurred six months ago while brushing her teeth, with a small amount of light pink blood, initially attributed to possible gum bleeding. The second episode was approximately one month ago, also after brushing her teeth, with a larger clump of dark red blood lasting a few minutes. The third episode occurred about three weeks ago, again with light pink blood, possibly after brushing her teeth. She attempted to differentiate whether the blood originated from her teeth or throat and believes it was from her throat. She denies associated breathlessness, fever, weight loss, or night sweats. She reports stable or slightly increased weight. She denies any prior personal history of asthma, but notes a possible episode of pneumonia last year, treated with antibiotics, characterized by a month-long cough and some difficulty breathing, but without hemoptysis at that time. She denies nosebleeds, vomiting blood, or current heartburn. She describes occasional allergy symptoms including nasal congestion, sneezing, itchy eyes, and cough. She notes occupational exposure to smoke from hair products, which sometimes induces coughing.
Exercise capacity: No limitations reported; denies breathlessness.
Number of exacerbations: No recent exacerbations requiring antibiotics, steroids, emergency visits, or hospitalizations.
Sputum or cough: Occasional cough, no regular sputum production.

Past Medical History:
- Possible pneumonia in the past year, treated with antibiotics.
- History of breast augmentation.

Medications:
- None

Drug Allergies:
- Allergic to an unspecified medication used to reduce swelling or pain after lip filler procedures.

Social History:
Smoking history: Never smoker
Occupation: Hair stylist with occupational exposure to smoke from hair products, especially during keratin straightening procedures
Pets: None
Travel: Born in xxx, immigrated to xxx in 1990

Family History:
Father had lung cancer and a history of tuberculosis; he was a smoker. Younger brother has asthma.

Physical Exam:
SpO2: 94%, Heart rate: 65 bpm
• Vital signs: SpO2 94% on room air, heart rate 65 bpm and regular
• General: No acute distress
• Chest: Clear lung fields without adventitious sounds, no digital clubbing, chest expansion within normal limits
• Cardiovascular: Unremarkable
• Extremities: No clubbing

Investigations:
- Sputum analysis from October 2025 was insufficient for analysis.

Chest Imaging:
- Chest x-ray from October 2025 is normal.

Pulmonary Function Testing:
- Pending

Labs:
- Pending

Assessment and Plan:
Mai Nguyen presents with recurrent episodes of hemoptysis over the past six months, with no associated constitutional or respiratory symptoms and a normal chest x-ray. Occupational exposure and family history are notable for lung cancer, tuberculosis, and asthma. The etiology of hemoptysis remains unclear, with possible sources including upper airway, dental, or lower respiratory tract. 
- Plan includes ordering a computed tomography scan of the chest at Regional Medical Center within the next month, arranging for non-fasting blood work at a local laboratory, and scheduling a follow-up appointment in one month to six weeks to review results. Pulmonary function testing will be performed at follow-up. Bronchoscopy will be considered if the CT scan is inconclusive or if further evaluation is warranted.

I will follow up with the patient after the investigations are completed and update you accordingly.

Sincerely,

Daniel Tran, MD
Respirology
xxx Health