A 71-year-old African-American woman presented to the emergency department with chest pain, shortness of breath, and cough. She had initially presented to her primary care physician 2 weeks previously complaining of worsening cough and shortness of breath and was told to continue her inhaled albuterol and glucocorticoids and was prescribed a prednisone taper and an unknown course of antibiotics. She noted no improvement in her symptoms despite compliance with this treatment. Three days prior to admission she described the gradual onset of left-sided pleuritic chest pain with continued cough, associated with yellow sputum and worsening dyspnea. Review of systems was remarkable for generalized weakness and malaise. She denied fever, chills, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, diarrhea, nausea, vomiting, or abdominal pain. Her past medical history included a diagnosis of chronic obstructive pulmonary disease (COPD) but pulmonary function tests 7 years prior to admission showed an forced expiratory volume in the first second (FEVI)/ forced vital capacity (FVC) ratio of 81%. She had a 30 pack-year history of smoking, but quit 35 years ago. The patient also carried a diagnosis of "heart failure," but an echocardiogram done 1 year ago demonstrated a left ventricular ejection fraction of 65% to 70% without diastolic dysfttnction but mild right ventricular dilation and hypertrophy, Additionally, she had known nonob-structive coronary atherosclerotic heart disease, dyslipidemia, hypertension, morbid obesit depression, and a documented chronic right hemidiaphragm elevation.