Picture quiz: End of the bed

History

During a clinical placement on a medical ward, the specialist registrar challenges you to make “an end of the bed diagnosis.” The patient is a 49 year old man, a former smoker, who presented with severe dyspnoea and pitting oedema in the lower limbs. He has a history of recurrent deep venous thrombosis and pulmonary embolism. From the end of the bed you can see the patient is wearing a face mask providing high flow oxygen, his jugular venous pressure is markedly raised, and the appearance of his abdomen is grossly abnormal (figure below).