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Clinical introduction A 60-year-old man had a long history of chronic hepatitis C. He presented to the emergency department with 2 days of progressive dyspnoea. Clinical manifestations included respiratory distress, cyanosis, digital clubbing, spider naevi on the upper chest and shifting dullness in the abdomen (see online supplementary figure S1). The ECG showed sinus tachycardia and left axis deviation. The chest radiography depicted blunting of right costophrenic angle with small pleural effusions and bilateral prominent pulmonary vascular markings (see online supplementary figure S2). The dyspnoea was exacerbated by upright posture and improved with recumbency. The hypoxaemia could not be corrected with administration of 100% oxygen. Contrast-enhanced transthoracic echocardiography was performed with injection of agitated saline (see figure 1 and online supplementary video). CT scan of the chest revealed some vascular abnormalities (see online supplementary figure S3–S6). Question Which of the following is the next best step in management? Catheter-based closure of intracardiac shunt Liver transplantation Pulmonary angiography and embolisation Thoracentesis Transjugular intrahepatic portosystemic shunt

A 76-year-old woman with a history of hypertension and diabetes mellitus presented to the ED with abdominal pain for 1 week. On physical examination, the patient was found to have epigastric and bilateral costovertebral angle tenderness. Laboratory tests reported elevations of white blood cell count, creatinine and serum lipase. A chest radiograph was obtained (figure 1). Figure 1 A chest radiograph of the patient. What is …

A 34-year-old man presented with a 1 day history of upper abdomen pain. Physical examination showed epigastric tenderness and rebounding pain. There was no abnormality in standing chest radiography. The plain abdomen revealed vertical oriented …