A 58‐year‐old smoker presents to his GP with a 6‐month history of progressive dyspnoea and weight loss. On talking to the patient it is noticed that he has a hoarse voice, which he says has been present for 3 months and he also admits to several episodes of haemoptysis. The GP is worried about the patient's appearance as he has lost 3 stone in weight since his last visit and is breathless at rest. He is referred to the acute medical take where a chest X‐ray is performed. This demonstrates large bilateral effusions and nodules in both lung fields.

On examination the patient has a respiratory rate of 32 breaths/min, oxygen saturations of 88% on air and stony dullness at both bases. He is cachectic with a 4‐finger breadth firm liver. The only other finding is that his right calf is warm and swollen with pitting oedema. The patient says that this has been present for approximately one week.