A 93-year-old female presented to the emergency department with a short history of exertional dyspnoea and right-sided shoulder pain. She was found to be hypoxic on room air. She was an ex-smoker and had a history of well controlled COPD. Despite her age she remained independent in activities of daily living, without history of functional or cognitive impairment. She had a past medical history of macular degeneration, transient is­chaemic attack (2007), subarachnoid haemorrhage (1985) and hypertension. Her drug history was of clopidogrel 75 mg daily only. Clinical examination revealed hyper-resonant percussion note, reduced air entry and decreased vocal resonance on the right. Initially recorded resting oxygen saturations were 96% on 4 L ⋅ min−1 oxygen via nasal cannulae, heart rate was 96 beats ⋅ min−1 and blood pressure 151/63 mmHg. A chest radiograph was performed.