A 41-year-old African American male with a past medical history of schizophrenia, polysubstance use with alcohol and methamphetamine, and homelessness presented to the hospital with auditory and visual hallucinations and homicidal ideation. He also reported intermittent fever, cough, right-sided chest pain, and dyspnea. Family history was unremarkable, with no history of contact with sick people recently. There was no recent travel history either.
Initial vital signs on admission included a temperature of 38.2  C, blood pressure of 120/74 mmHg, heart rate of 105 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 98% on ambient air. Physical examination revealed a thin male without apparent distress but appeared disheveled and mildly anxious, fully oriented with normal speech, and without adenopathy. Respiratory examination showed right lung crackles, but the rest of the systemic examination was normal.
Laboratory data showed normal metabolic panel and serum lactate, no anemia or leukocytosis but mild eosinophilia at 0.52 thousand/mcL. The urine drug screen was positive for methamphetamine. Both polymerase chain reactions for SARS-CoV-2 and HIV were negative. The tuberculosis QuantiFERON test was also negative. An anterior-posterior chest X-ray revealed a right lower lobe consolidation with an air bronchogram (Figure 1).
A cardiac workup ruled out acute coronary syndrome and ECG showed regular rate and rhythm without any change from baseline, as shown in Figure 2. 
The patient was initially treated for community-acquired pneumonia with antibiotics without clinical response. Coccidioidomycosis IgG and IgM antibodies came back positive, and the patient was started on fluconazole. Psychiatric consultation was also obtained, given the patient's symptoms, and showed that the patient was no more suicidal but was homeless and said, "I know what to say to stay in the hospital." The psychiatrist suspected malingering as a potential cause of his psychiatric symptoms. Two days later, the patient started to complain of new onset of left-sided chest pain, away from the site of his original right-sided pleuritic chest pain from pneumonia. Repeat ECG and serum troponin were unremarkable. The chest pain was initially attributed to either mild left-sided involvement of the patient's coccidioidomycosis pneumonia or malingering, but POCUS was performed at the bedside for further evaluation. Unexpectedly, it showed RV strain with D-shaped left ventricle and lung B-lines with subpleural consolidations, not previously seen on admission (Figures 3-4).
No deep venous thrombosis (DVT) was found. The D-dimer level was elevated at 1,453 D-dimer units (DDU) ng/mL and subsequent CTPA confirmed the presence of bilateral pulmonary emboli in the left and right upper lobes but greater in the left (Figure 5).
Testing for genetic thrombophilic diseases, including cardiolipin IgG, IgM, IgA, protein C activity, protein S level, antithrombin III functional level, and Factor V Leiden mutation, were all negative.