…significant RV dilatation and septal bowing. On CT, the patient was confirmed to have a large PE clot burden. This case highlights how doing a quick echo can be very revealing if there is suspicion of or confirmed DVT! It can show if there is a significant PE causing cardiac strain which can explain hemodynamic instability. In image A, the apical 4-chamber view shows abnormal bulging of the RV and septum into the LV. RV size can be assessed from any window although most suggest using the apical 4-chamber view and comparing relative sizes at the level of the atrioventricular valves. The RV should normally be < 2/3 of the LV. Image B is a terrific example of "septal bowing" which represents abnormal interventricular septal motion. Because of the increased RV pressure in this case, the interventricular septum flattens in diastole and is best seen in the parasternal short-axis as a "D-shaped left ventricle". (see arrow) In addition to those above, you can also directly visualize the clot in the right heart or pulmonary artery (very rare), identify tricuspid regurg, a distended IVC with lack of respiratory collapse, and RV hypokinesis with apical sparing (known as McConnell's sign – not very sensitive or specific but extremely cool. Dr Norris captured an incredible clip of this sign if you'd like to see it, we would love to show it off!) We know that patients with PE and RV dysfunction on echo have substantial morbidity and mortality and using bedside echo to establish this diagnosis early and quickly allowing for risk stratifying can be critical to these patients and make a difference in their outcomes. This is especially helpful when the patient is too unstable for CT.