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Case65 y/o lady presents to the ED with acute onset shortness of breath started 6 hours ago. She has history of DM, HTN, DLD. Just prior to this episode she felt like her heart was racing. She is axnious. She denies any previous dyspnea on exertion, lower extremity swelling or abdominal distension. She had been feeling well the day prior.In ED her vitals were 36.5 125 192/100 27 83% on RA. She was in Resp distress, sweaty seated upright. S1, S2 and S4 heard, irregular with no m/g/r and no JVD29931

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