“I think it’s time we go on ambulance diversion again,” your charge nurse suggests, looking as tired and frustrated as you feel. This is the third time this week that you have had to close your ED. All of the beds in the hospital are full, and your ED is bulging at the seams with sick patients that aren’t going anywhere anytime soon. You are holding 10 admissions at the present moment, and the hallways are lined with patients calling “doctor” every time you walk by.

As much as you hate doing so, you concede to the request to close to ambulance traffic and then walk briskly over to the chart rack to see what you can do to help improve the current situation. Your eager intern is right on your heels and says he has a new patient to present to you. “This should be a really simple case,” he spurts out. You raise your eyebrows and bite your tongue.

The intern paints a story of a 40-year-old female who came into the ED today because she was feeling “under the weather”. She’s had a cough and nasal congestion on and off for the past 4 weeks. The cough has been productive of yellowish-white mucus, and the same stuff is seen running down her posterior pharynx on exam. She’s also reporting tactile fevers, chills, myalgias, and a headache. Coughing makes the headache worse, but she has no neck pain or neck stiffness, and the headache came on gradually and is not that severe. She also complains of some chest pain, and states it feels like a “sharp pain in her heart” that’s worse when she coughs. Her throat hurts, her ears ache, and just like everyone else in your ED, she thinks she has the flu.

Other than the post-nasal drainage in her throat, her only significant exam findings are some faint crackles in the left lung base and a mild pharyngitis. Your intern wants to order a chest x-ray, a flu-swab and a urine pregnancy test and provide her with some supportive therapy both in the ED and as an outpatient after she gets discharged. He recommends some IV fluids for her heart rate of 118 bpm, Tylenol for her headache and some Tessalon Perles for the cough. He doesn’t think she has strep pharyngitis based on the Centor criteria, and so he doesn’t want to test for that.

On the way to go see the patient you grab the ultrasound machine and comment, “Teaching point number one is conservation of energy. One of the best ways to be efficient is to ensure that you minimize the amount of time wasted. If you might need the ultrasound machine, take it with you so you don’t have to walk back out of the room to go get it.”

When you enter the room, you see that your intern’s presentation was pretty accurate. The poor lady looks miserable and she is sitting in the bed, hunched over her knees, coughing up some yellowish-white sputum. You wash your hands, introduce yourself, and take advantage of the moment to listen to her lung fields with her sitting upright and leaning forward. You take a quick peek at her lungs with the ultrasound machine and note that there is no obvious pneumothorax, consolidation, or pleural effusion. You have her lie back in the bed so you can perform the rest of the exam. As reported, she likely has a mild viral pharyngitis and no concerning signs for meningitis. As you are about to listen to her heart sounds, the patient asks if she can sit up because her chest feels better when she leans forward. Your Spidey-sense tells you that something isn’t quite right, so you place the phased array ultrasound transducer over her heart and obtain the following parasternal long-axis view (Image 1). What do you see? What could this be from?


You place the phased array ultrasound transducer over her heart and obtain the following parasternal long-axis view. What do you see? What could this be from?  Conclusion on next page



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