• Robert Mintz and Kevin Brody.
• Henry Ford Macomb Hospital, Clinton Township, Michigan 48038, USA.
• J Emerg Med. 2013 Jul 1;45(1):19-21.

BackgroundA thrombus straddling a patent foramen ovale (i.e., impending paradoxical embolism) is a very rare event. Most cases have been reported at autopsy only after finding a patent foramen ovale and arterial emboli. Patent foramen ovale in the population is common.ObjectivesThe objective of this case report is to remind physicians that common presentations can have uncommon causes. Some of these uncommon causes are easy to find and may significantly change outcomes if treated early.Case ReportWe present the case of a dyspneic patient with concomitant pulmonary embolism, deep vein thrombosis, and impending paradoxical embolism. Emergency Physicians should be aware that dyspnea may be the only initial symptom. Although dyspnea may be linked to a pulmonary embolus, it may not represent the entire clinical picture. A thrombus formed within a patent foramen ovale portends the possibility of a larger pulmonary embolus and an arterial embolus.ConclusionEarly detection of an impending paradoxical embolism may result in an improved outcome. Treatment choices consist of anticoagulation, thrombectomy, or thrombolysis. Choice of treatment is difficult but should be made quickly to reduce the possibility of adverse patient outcomes.Copyright © 2013 Elsevier Inc. All rights reserved.

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