A 16-year-old girl comes to the ED because of acute shortness of breath and “coughing up a cup of blood.” She has been diagnosed as having asthma and uses bronchodilators as needed. Over the past 7 months, her cough and wheezing episodes have increased, and she has produced blood-streaked sputum but has not sought care. She denies any fevers, weight loss, lethargy, decreased appetite, unusual travel, or major illness.

On physical examination, she is uncomfortable and is breathing at 35 breaths/min but without respiratory distress. Her temperature is 98.5°F (37°C), heart rate is 96 beats/min, blood pressure is 129/66 mm Hg, and oxygen saturation is 95% by pulse oximetry. Breath sounds over the right hemithorax are diminished, but no retractions, wheezing, or crackles are noted. The remaining physical findings are normal.

Her Hgb concentration is 14.1 g/dL (141 g/L), WBC count is 14.6×103/mcL (14.6×109/L) (90% neutrophils,...

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