Pseudo-hemoptysis in postoperative patients as an emergency medical service diagnostic pitfall when evaluating for pulmonary embolism: a case report
Article information
Abstract
This case report describes a postoperative patient whose apparent hemoptysis created a diagnostic challenge. The risk of postoperative venous thromboembolism increases approximately 20- to 40-fold after major surgery. This increased risk is attributed to postoperative immobility, surgery-induced hypercoagulability, and endothelial injury. Hemoptysis is defined as the expectoration of blood or blood-tinged sputum originating from the lungs or tracheobronchial tree. In practice, however, distinguishing true hemoptysis from bleeding that originates in the upper airway or nasopharynx can be difficult. In postoperative patients, hemoptysis is classically associated with pulmonary embolism (PE), although hemoptysis has been reported in only 10%–20% of patients with confirmed PE. Emergency medical services and emergency department clinicians frequently encounter diagnostic uncertainty in this setting, and PE remains commonly missed or misdiagnosed. Approximately 27.5% of patients with PE are initially misdiagnosed in emergency department settings, and recent national data suggest that at least 400 excess deaths from PE occurred in England between April 2021 and March 2022 because of missed diagnoses.
INTRODUCTION
This case report describes a postoperative patient whose apparent hemoptysis created a diagnostic challenge. Surgery is not an independent baseline risk factor for venous thromboembolism (VTE); however, it is recognized as a major transient provoking factor. The risk of postoperative VTE increases approximately 20- to 40-fold after major surgery and, in procedures such as laparoscopic cholecystectomy, by an estimated three to five times [1,2]. This increased risk is attributed to postoperative immobility, surgery-induced hypercoagulability, and endothelial injury. In this patient, additional baseline risk factors, including established coronary artery disease and obesity, further increased the underlying probability of thromboembolic disease. Hemoptysis is defined as the expectoration of blood or blood-tinged sputum originating from the lungs or tracheobronchial tree. In practice, however, distinguishing true hemoptysis from bleeding that originates in the upper airway or nasopharynx can be clinically difficult. In postoperative patients, hemoptysis is classically associated with pulmonary embolism (PE), although hemoptysis has been reported in only 10%–20% of patients with confirmed PE [3].
Emergency medical services (EMS) and emergency department (ED) clinicians frequently encounter diagnostic uncertainty, and PE remains commonly missed or misdiagnosed. Approximately 27.5% of patients with PE are initially misdiagnosed in ED settings, and recent national data suggest that at least 400 excess deaths from PE occurred in England between April 2021 and March 2022 because of missed diagnoses [4,5]. The diagnostic utility of D-dimer testing is well established; when the estimated probability of PE exceeds 2%, D-dimer measurement is considered useful because the potential iatrogenic harm of further investigation is outweighed by the risk of failing to diagnose PE. Ethics review was exempted by the Nursing and Paramedic Science Divisional Research Ethics Committee, Queen Margaret University (Ref. QMUETH1027).
CASE REPORT
The patient had undergone an uncomplicated laparoscopic cholecystectomy 4 days before the emergency call. His medical history included coronary artery disease, with two coronary stents placed during a non-urgent angiographic procedure 7 years earlier. No additional significant comorbidities were reported. Since discharge, the patient had experienced a persistent, nonspecific feeling of being unwell. On the night before presentation, he awoke twice to urinate and felt that he needed to clear material from his airway. This sensation precipitated episodes of forceful coughing, during which he expectorated large, gelatinous, dark-red clots. The initial episode was undocumented because the patient disposed of the clots. A subsequent episode occurred the following morning, when his wife photographed three discrete clots, each approximately 2.5–3 cm in size, dark red, gelatinous, and without associated sputum.
Concerned that the patient was coughing blood and perceiving his breathing as “shallow” and abnormal, his wife contacted EMS. Because no ambulance was available, a solo-responder paramedic unit was dispatched. The call was categorized under AMPDS as 21D04M, “Hemorrhage/Laceration with abnormal breathing.” On arrival, the patient was alert, ambulatory, and clinically stable in appearance. Assessment was conducted while he was seated on his sofa. Vital signs obtained during the EMS assessment are summarized in Table 1. The patient denied chest pain and reported only mild shortness of breath. He did not perceive his breathing as abnormal, although his wife remained concerned.
Clinical findings during EMS assessment
The patient was advised to self-present to the nearest ED, which was located at a tertiary teaching hospital. Triage observations were within normal limits, including a respiratory rate of 18 breaths per minute. Electrocardiogram (ECG) findings remained unremarkable. Examination by an emergency medicine registrar included anterior rhinoscopy, which identified dried blood in the left nasal cavity consistent with recent epistaxis. No blood was visualized in the right nostril.
This case created a diagnostic challenge for EMS clinicians because the patient had recent surgery, elevated baseline risk of VTE, and expectorated blood. In the pre-hospital setting, thorough rhinoscopy is generally not feasible. Interpretation of a D-dimer assay would also have been limited by the high likelihood of postoperative elevation, potentially leading to unnecessary computed tomography pulmonary angiography. Using the revised Geneva score, the patient would be classified as moderate risk, corresponding to an estimated 20%–30% incidence of PE in several studies. Application of the Wells score yielded 5.5 points, also placing him in a moderate-risk category, with an estimated 16.2% probability of PE in an ED population. Other studies categorize scores >4 as “PE likely,” with an approximate 28% incidence. However, interpretation of the expectorated blood was central to risk stratification. If the material was judged not to represent true hemoptysis but instead to be secondary to nocturnal epistaxis with posterior drainage, the pre-test probability of PE would be substantially reduced. Under this interpretation, the patient would fall into a low-risk category: 7%–9% incidence by Geneva criteria and approximately 1.3% by Wells criteria. Studies that categorize Wells scores ≤4 as “PE unlikely” report a 3% incidence of PE.
DISCUSSION
True hemoptysis, defined as expectoration of blood originating from the lower respiratory tract, is a recognized but relatively uncommon presenting feature of PE, with an estimated prevalence of 10%–20% in confirmed cases. Differentiating true hemoptysis from pseudo-hemoptysis—that is, blood arising from the upper airway, gastrointestinal tract, or nasopharynx—remains a well-documented diagnostic pitfall. This distinction is especially difficult in emergency settings, where clinicians often rely on patient descriptions and limited witnessed evidence. In postoperative patients with elevated thrombotic risk, expectorated blood often prompts PE-directed investigation; accurate classification is therefore important to avoid unnecessary radiation exposure and contrast administration when PE is otherwise unlikely.
Epistaxis, particularly when it occurs during sleep, can be misinterpreted as hemoptysis when swallowed blood drains posteriorly into the oropharynx. Nocturnal episodes may be unwitnessed, and patients may awaken with a need to cough or clear their throat, leading to expectoration of clotted blood. In this case, the dark, gelatinous appearance of the clots and the absence of associated sputum were consistent with overnight pooling and partial coagulation of blood in the nasopharynx. The subsequent identification of dried blood in the left nasal cavity on rhinoscopic examination supported epistaxis as the likely bleeding source. Failure to recognize nocturnal epistaxis as a mimic may prompt unnecessary diagnostic evaluation for PE, upper gastrointestinal bleeding, or pulmonary pathology. EMS clinicians face a specific barrier in this setting: the equipment and environment needed for a thorough rhinoscopic examination are often unavailable, limiting their ability to identify unilateral nasal blood as evidence of epistaxis.
Physical examination played a central role in resolving the diagnostic ambiguity. Anterior rhinoscopy revealed dried blood in the left nasal cavity, providing direct evidence of recent epistaxis. The absence of oral cavity bleeding, normal respiratory examination findings, and stable vital signs further argued against an active pulmonary source. However, these findings did not definitively exclude PE. The finding of unilateral nasal blood was clinically important because it offered a plausible source for the expectorated clots and was unlikely to be incidental in this context. This case therefore underscores the value of a careful upper-airway examination when patients present with suspected hemoptysis.
This case demonstrates the diagnostic complexity that arises when reported hemoptysis is later found to have an upper-airway origin. In postoperative patients, baseline PE risk is elevated and D-dimer interpretation is difficult; therefore, even small uncertainties in symptom characterization can meaningfully influence clinical reasoning. In this patient, dried blood within a single nostril offered a plausible explanation for the expectorated blood, but this finding did not exclude concurrent pulmonary pathology. Importantly, PE was not definitively ruled out, and this discussion should therefore be understood as an analysis of diagnostic reasoning rather than confirmation of a final diagnosis.
The different outputs of validated risk-stratification tools, depending on whether hemoptysis was accepted as genuine, illustrate the sensitivity of these models to symptom interpretation. This case highlights the value of clarifying the bleeding source early, not to alter established practice, but to show how misclassification can shift patients between risk categories and potentially influence downstream decision-making. These insights are reflective rather than prescriptive. They do not imply that recognizing pseudo-hemoptysis will reduce imaging use or change EMS pathways; instead, they indicate that accurate symptom characterization supports more reliable application of existing diagnostic frameworks.
This case is also consistent with literature describing epistaxis, particularly nocturnal epistaxis, as a recognized mimic of lower-airway bleeding. Although this evidence helps contextualize the patient’s presentation, epistaxis and PE should not be viewed as mutually exclusive. In postoperative patients, both conditions may coexist, and clinicians should remain open to parallel explanations rather than anchoring on a single bleeding source.
For EMS and ED clinicians, this case offers a practical reminder: early identification of potential upper-airway bleeding may refine pre-hospital and ED assessment by helping ensure that hemoptysis is neither overinterpreted nor underinterpreted. This point is not intended to suggest changes to transport decisions, pre-alert activation, or imaging thresholds. Rather, it emphasizes the importance of careful history-taking and examination in settings where rapid decisions are required. Ultimately, this case illustrates how small diagnostic details can shape clinical reasoning and reinforces the value of maintaining a broad, balanced differential diagnosis in postoperative patients who present with apparent hemoptysis.
In this case, the patient self-presented to the regional teaching hospital on the paramedic’s recommendation. He was assessed by a specialist registrar in emergency medicine and discharged with a primary diagnosis of nocturnal epistaxis and a secondary diagnosis of post-surgical general malaise. The patient spent approximately 4 hours in the ED. His diagnostic workup consisted of basic clinical observations and a 12-lead ECG; no laboratory testing or additional investigations were requested. No thromboembolic or other adverse events were reported, and the patient did not re-engage with emergency health services within 30 days after discharge.
Notes
FUNDING
None.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.