Dan, a 39-year-old generally well restauranteur, fell while lifting cartons of wine, landing heavily on the right side of his chest wall. He presents later that day to his GP with significant localised right chest wall pain despite having taken paracetamol and ibuprofen. 

Dan has a background of obesity, with a BMI of 31kg/m² (weight 100kg, height 178cm). He smokes 20 cigarettes a day and has noticed increasing shortness of breath on exertion over the past few years. He has no known allergies and takes no regular medications.

Dan’s vital signs are within normal limits. He has bruising, chest wall tenderness and slightly reduced breath sounds on the right. A substantial umbilical hernia is evident, 8cm in diameter, with minimal associated discomfort and no firmness or significant pain to suggest incarceration.

FBC, biochemical screen, lipid studies and glucose are normal. Chest X-ray demonstrates undisplaced fractures of the right anterior sixth and seventh rib, corresponding to the site of maximal discomfort and bruising. There is basal shadowing in the right lung field — possibly representing a diaphragmatic hernia and right basal atelectasis.