[Clinical thinking and decision making in practice. A patient with pain in the upper abdomen]

A 74-year-old woman was admitted because of abdominal pain. A few weeks before this admission she had had a cerebral infarction in the right hemisphere, reflected by a left sided paralysis, dysarthria, depression and a slight cognitive disorder. The night before admission she woke up from a sharp, continuous pain in the right upper abdomen. Physical examination disclosed pain in the right upper abdomen on palpation. Laboratory tests showed a slight elevation of all 'liver' enzymes. A differential diagnosis of cholecystitis or pyelonephritis was made. Additional tests did not confirm either of these diagnoses. Because of immobilisation pulmonary embolism was then suspected. This diagnosis was confirmed by scintigraphy. The patient was treated and made a full recovery. Diagnostic errors can be made by faulty triggering and omitting verification. The diagnostic strategy for pulmonary embolism is a ventilation perfusion scan, which is followed in case of a non high-probability result by pulmonary angiography. It is emphasized that the presentation of pulmonary embolism can be aspecific.