Pulmonary Embolism With Pulmonary Infarction Despite Low-Risk Prediction Scores: Atypical Pleuritic, Abdominal, and Shoulder Pain

Clinical prediction tools for pulmonary embolism (PE), such as the Pulmonary Embolism Rule-out Criteria (PERC) rule, Wells score, and Geneva score, are designed to detect the classically described clinical signs and risk factors of PE and do not account for pleuritic pain syndrome, which can be the leading clinical presentation when PE causes pulmonary infarction (PI).We describe a 27-year-old male driver and hookah user who presented with dyspnea, pleuritic chest pain, back pain, and abdominal pain -atypical features that initially raised concern for aortic dissection.Clinical prediction scores yielded a low pretest probability despite subsequently confirmed PE, and D-dimer was near-threshold.CT angiography revealed subsegmental PE with PI.