RT Journal Article SR Electronic T1 Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale JF BMJ Case Reports JO BMJ Case Reports FD BMJ Publishing Group Ltd SP e242351 DO 10.1136/bcr-2021-242351 VO 14 IS 10 A1 Tessa Houtzager A1 Ingvar Berg A1 Thijs Urlings A1 Robert Grauss YR 2021 UL http://casereports.bmj.com/content/14/10/e242351.abstract AB A 78-year-old female patient presented to the emergency department with syncope and dyspnoea. The left arm appeared to be cold and radial pulse was not palpable. A CT scan of the chest and left arm with intravenous contrast displayed bilateral central pulmonary embolisms in combination with a left subclavian artery embolism and an atrial septal aneurysm. Transthoracic echocardiography identified a patent foramen ovale with right-to-left shunting confirming the diagnosis of paradoxical embolism. The patient was treated with anticoagulants. In a patient presenting with a combination of a pulmonary embolism and a peripheral arterial embolism, the clinician should consider a right-to-left shunt with paradoxical embolism. In line with this, when diagnosing a peripheral arterial embolism, a central venous origin should be considered. Furthermore, when diagnosing a pulmonary embolism or other forms of venous thromboembolism, the clinician should be aware of signs of a peripheral arterial embolism.