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A 34-year-old woman presented to the ED with dyspnea that began three hours earlier.

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The ambulance call report clearly captures the essence of the patient’s clinical presentation (Figure 1).

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Her chief complaint was: “I can’t breathe.” She had dull substernal chest pain. The ambulance crew noted that she was “hysterical and hyperventilating” and that she was taking birth control pills. During the previous month, she had had episodes of shortness of breath and dull chest pain.

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She appeared ill, and the presumptive diagnosis was “rule-out myocardial infarction.”

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On arrival in the ED, she was anxious and in mild respiratory distress. Her vital signs were: blood pressure 120/80 mm Hg, pulse 104 beats/min, respiratory rate 24 breaths/min, and she was afebrile. Her oxygen saturation by pulse oxymetry was 88% on room air and 94% on 4 L/min oxygen administered by nasal cannula.

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On examination, her lungs were clear to auscultation and her heart was rapid and regular without murmur, pericardial friction rub, or gallop. Her abdomen was not tender and there was no lower extremity edema or tenderness. She was overweight.

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Blood tests, EKG, and chest radiographs were obtained. The EKG revealed sinus tachycardia and nonspecific T-wave flattening.

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The chest radiographs were interpreted as being “normal” (Figure 2).

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A bolus and infusion of heparin was administered by intravenous catheter.

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  • Should you order a chest radiograph in this patient?
  • What are you looking for?

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(There are three significant radiographic findings.)

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Pulmonary embolism (PE) was the primary diagnostic consideration in this patient. Although the radiograph was initially interpreted as normal, there are three significant findings: (1) blunting of the right costophrenic sulcus; (2) relatively increased opacity at the left lung base; and (3) an enlarged left hilum (Figure 3).

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Figure 3
Graphic Jump Location

Patient 4—AP view (see text for explanation).

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Blunting of a costophrenic sulcus is most often due to a small pleural effusion, a finding that is sometimes seen in patients with PE (Figure 3, arrowhead). However, on the lateral view, the posterior costophrenic sulci are sharp rather than fluid-filled, as would be expected with a pleural effusion (Figure 4, arrow). In addition, pleural fluid generally creates a meniscus with a concave-up contour rather than convex, as seen on this patient's AP view. The opacity is therefore not a pleural effusion, but instead represents ...

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