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A 24 year old woman was admitted to our hospital for a massive haemoptysis with abrupt onset. The average amount of blood expectorated was 200–250 ml in 24 hours. She was a non-smoking housewife living in a rural area. Her medical history was unremarkable except for the presence of recurrent oral and genital ulcers for three years, and skin lesions consistent with erythema nodosum had occurred one year previously. Her vital signs on admission were as follows: temperature 37°C, blood pressure 110/70 mm Hg, pulse rate 120 beats/min, and respiratory rate 28 breaths/min. Physical examination of the chest was normal. Admission laboratory values were as follows: leucocyte count 9.3 × 109/l, haemoglobin concentration 120 g/l, packed cell volume 0.34, platelet count 42 × 109/l, erythrocyte sedimentation rate 44 mm/hour, alanine aminotransferase 48 IU/l (normal range 0–40 IU/l), aspartate aminotransferase 34 IU/l (normal range 0–40 IU/l), lactate dehydrogenase 657 IU/l (normal range 240–480 IU/l). Serum electrolytes, renal function, urinalysis, prothrombin time, and activated partial thromboplastin time were all in the normal ranges. Her chest radiograph showed two rounded opacities bilaterally with fine margins with an average size of 3 × 5 cm (fig 1). Purified protein derivative by Mantoux testing was 17 mm.
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What possible diagnoses are compatible with the patient's clinical presentation?
What is the most likely diagnosis?
What investigations would you perform to confirm your diagnosis?
How would you manage this patient?
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