A twenty year-old black female presents to the emergency department complaining of gradually worsening shortness of breath, very gradually worsening over 3 months. She tried her friend's inhaler but it provided no relief. Her only other complaint elicited on review of systems is a new bothersome rash on her shins.
On exam she is a slender woman. Vitals are normal. She has trace wheezes in the mid to upper lung fields bilaterally. Her breaths are somewhat shallow even when asked to "take a deep breath". She has about a dozen slightly raised, tender, mildly erythematous round lesions approximately 1cm in diameter on her pre-tibial legs bilaterally.
Labs are notable for an alkaline phosphatase of 156. Her calcium was elevated at 10.8. Other labs were unremarkable.
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