A 73-year-old woman presents to the emergency department complaining of increasing breathlessness over the previous 4 days. She had felt unwell for 2 months and has lost 4 kg in weight. She has had frequent nosebleeds, and over the past few days has coughed up small amounts of fresh blood. She notices that she has been passing less urine in the past few days. She has no significant past medical history. Examination On examination, she is febrile (38 0C), centrally cyanosed and looks unwell.
She has a purpuric rash over her ankles. Her pulse is 104/min, blood pressure 160/100 mmHg. Her jugular venous pressure is not raised. Her heart sounds are normal with no added sounds. Her respiratory rate is 30 breaths/min, expansion is reduced, percussion and tactile vocal fremitus are normal but she has coarse inspiratory crackles throughout both lung fields. Her abdominal and neurological…
