69-year-old female woke from sleep at 3 AM with acute, severe shortness of breath and a sense of drowning. She is hunched forward on the stretcher in a tripod position, unable to speak in full sentences, and appears terrified. She has a productive cough with frothy, pink-tinged sputum. Her husband says she 'sounded like she was gurgling' when he found her.

History of chronic systolic heart failure (EF 25%), hypertension, and atrial fibrillation. Medications include furosemide 80mg daily, lisinopril, carvedilol, digoxin, and warfarin. She states she has been eating normally but forgot to take her furosemide for the past three days. She denies chest pain or chills. Her legs have been 'a little puffier' this week.

BP 204/118 mmHg, HR 116 bpm (rapid ventricular response atrial fibrillation), RR 36 breaths/min, SpO2 82% on room air — increased to 91% on 15L non-rebreather mask, Temp 36.8°C. Patient is in severe respiratory distress, using all accessory muscles, unable to lie flat. Anesthesia called to bedside.

Diffuse bilateral crackles on auscultation from bases to apices — 'wet' lung sounds throughout. Frothy pink sputum visible at the mouth. S3 gallop present. Bilateral lower extremity pitting edema 3+. JVD elevated at 45 degrees. High-flow O2 transitioned to CPAP at 10 cm H2O — SpO2 improved to 96% within 5 minutes. IV furosemide 80mg given. IV nitroglycerin infusion started to reduce preload and afterload. Continuous cardiac monitoring.

BNP: 4,100 pg/mL (severely elevated). Troponin I 0.6 ng/mL (mildly elevated from demand ischemia). ABG on CPAP: pH 7.33, PaO2 64 mmHg, PaCO2 48 mmHg, HCO3 23 — combined respiratory failure and early respiratory acidosis. Chest X-ray: severe cardiomegaly, bilateral perihilar alveolar infiltrates in classic 'butterfly' pattern, bilateral pleural effusions, Kerley B lines. Bedside echo: EF visually estimated at 20–25%, severe global hypokinesis, dilated left ventricle.

Diagnose It — Archive Puzzle #17