28th SMS, A case
CASE SCENARIO ,,, A 73 year old woman presented to the ER complaining of increase breathlessness over the previous 4 days. She has felt unwell for two months and has lost 4 kg in weight. She has frequent nosebleeds, and over the past few days had coughed up small amounts of fresh blood. She noticed that she has been passing less urine in the past few days.
On examination, she is febrile (38C), centrally cyanosed and looks unwell. She has a purpuric rash over her ankle. Her pulse is 104/min regular, blood pressure 120/90. Her JVP is not raised. Her hearts sounds are normal with no added sounds. Her respiratory rate is 30 breathe/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 examination is normal. Investigations: Hemoglobin 10.1 g/dl, white call count 17.2 x 10^9/l, platelets 540 x 10^9/l, potassium 6.6 mmol/l, bicarbonate 8 mmol/l, creatinine 832 umol/l, albumin 32 g/l, phosphate 1.9 mmol/l, Arterial blood gases: pH 7.18, pCO2 5.1, pO2 6.4, Urinalysis: ++protein, +++blood, urine microscopy: > 100 red cells; red cell casts; no organisms, ECG: sinus tachycardia
What is the likely diagnosis?
How would you manage and investigate this patient?