In each issue, JUCM will challenge your diagnostic acumen with a glimpse of x-rays, electrocardiograms, and photographs of dermatologic conditions that real urgent care patients have presented with. If you would like to submit a case for consideration, please e-mail the relevant materials and presenting information to editor@jucm.com.

A 36-year-old obese woman presents with upper right back pain 10 days after a normal child birth. Pain is worse on coughing. Otherwise, she is fit and well.

Upon examination, you find:

No shortness of breath

Normal oxygen saturation

Patient is afebrile

Auscultation: Reduced breathing sounds in right base, fine crackles on right

View Figure 1, take these findings into account, and consider what your next steps would be. Resolution of the case is described below.

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The Resolution

Initially, the radio-opacity seen in the right base was interpreted as pleural effusion. The official read of the chest x-ray led to suspicion of Hampton’s hump in the right lower lobe.

Though the patient never had any shortness of breath, in view of her unusual pain, pathological x-ray, recent childbirth, and obesity, she was referred to hospital, where chest computed tomography showed a massive pulmonary embolus (PE).

Conclusion

It was imperative to rule out PE in this case. Factors that might have led the physician to discount that possibility—no shortness of breath or signs of deep-vein thrombosis and an x-ray that failed to inspire suspicion—should be overshadowed by the patient’s risk factors and recognition that plain film may show little evidence of PE (Figure 2).

Acknowledgment: Case presented by Ohad Sheffy, MD, who treated and referred the patient described.