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A 28 year old morbidly obese female presents with five days of dyspnea and chest tightness. She presented via EMS after having a syncopal episode at church. She has no past medical history and the only medication she takes is oral contraceptive pills that she has been on for 8 years. Her vitals signs are: BP 98/54, HR 136, RR 28, T 37.3. Her physical exam reveals her to be in moderate distress. Her pulmonary exam reveals clear lung sounds bilaterally. Her heart is regular without murmurs, rubs or gallops. She has no JVD, ankle edema or stigmata of a deep venous thrombosis. You order an EKG. A chest radiograph reveals no acute process per radiology. You are concerned about the possibility of a PE. You perform a focused bedside echo and note the following......
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