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A previously well 16-year-old girl presented to the adult emergency department with a 7-day history of sudden onset right-sided pleuritic chest pain. She had no associated cough, fever, breathing difficulty, palpitations or risk factors for pulmonary embolism. Examination was unremarkable apart from possible fourth left rib costochondral tenderness. White cell count (WCC) and C reactive protein (CRP) (3 mg/dL) were normal. Non-steroid anti-inflammatory drugs were prescribed. She re-presented 7 days later with ongoing chest pain. Clinical examination revealed no chest wall deformity, no increased work of breathing or tachypnoea and oxygen saturations of 98% in air. Air entry was reduced at the right base. Repeat blood tests demonstrated a minimal rise in CRP (21 mg/dL) and a normal WCC. Her chest X-ray was reviewed (figure 1). Verbal radiology report suggested that the appearance was consistent with a complication of pneumonia: ‘it's just a fluid level’.
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