- A 69-year-old man presented to the emergency department with fever and increased shortness of breath. He had a history of lung disease and recent pneumonia. - Initial examination and tests suggested pneumonia again, but a follow up CT scan identified a pulmonary embolism as the cause. - While the initial pneumonia diagnosis was logical given his history and a positive urine test, the normal chest x-ray should have prompted consideration of alternative diagnoses. Improved communication and consideration of test limitations may have led to earlier identification of the pulmonary embolism.