74-year-old male with a history of cardiac disease presents with a 4-day history of progressive shortness of breath, worsening significantly over the past 24 hours. He is now unable to lie flat and has been sleeping in a recliner. He reports swollen legs and states he has gained 8 pounds in the past week despite taking his 'water pill.'

Known history of ischemic cardiomyopathy with ejection fraction of 30% on last echo 6 months ago. History of hypertension, atrial fibrillation, and prior CABG x3 vessels 5 years ago. Medications include carvedilol, lisinopril, furosemide 40mg daily, spironolactone, and digoxin. He admits he ate 'a lot of salt' at a family gathering over the weekend and skipped his furosemide twice.

BP 168/94 mmHg, HR 96 bpm (irregularly irregular), RR 26 breaths/min, Temp 36.9°C, SpO2 87% on room air — improved to 94% on 6L nasal cannula. Patient is in visible respiratory distress, orthopneic, and cannot complete sentences without pausing to breathe.

Jugular venous distension noted at 45-degree angle. Bilateral crackles heard throughout all lung fields, worse at the bases. S3 gallop auscultated. 3+ pitting edema bilateral lower extremities to the knees. Abdomen: hepatomegaly palpated, patient reports right upper quadrant fullness. IV furosemide 80mg given; Foley catheter placed to monitor urine output.

BNP: 2,840 pg/mL (severely elevated; normal <100). Troponin negative x1. BMP: Na 131 mEq/L (dilutional hyponatremia), K 3.2 mEq/L (low from diuresis), creatinine 1.6 mg/dL (mildly elevated at baseline). Chest X-ray: cardiomegaly, bilateral interstitial and alveolar infiltrates in a bat-wing pattern, Kerley B lines, bilateral pleural effusions. Echo ordered.

Diagnose It — Archive Puzzle #8