A 66-year-old woman presents to your office complaining of shortness of breath and bilateral leg edema that have been worsening for 3 months.

A 66-year-old woman presents to your office complaining of shortness of breath and bilateral leg edema that have been worsening for 3 months. She emphatically tells you, “I get out of breath when I do housework and I can’t even walk to the corner.” She has also noticed difficulty sleeping secondary to a dry cough that wakes her up at night and further exacerbation of her shortness of breath while lying flat. This has forced her to use three pillows for a good night’s sleep. She takes no medications. She’s never smoked and drinks socially. On examination, her blood pressure (BP) is 187/90 mm HG, her pulse is 97 beats/min, her respiratory rate is 16 breaths/min, her temperature is 98 F (36.6 C), and her oxygen saturation is 93% on room air by pulse oximetry. She has a pronounced jugular vein. Cardiac examination reveals a pansystolic murmur. Examination of her lung bases produces dullness bilaterally. You find 2+ pitting edema of both ankles. An electrocardiogram (ECG) shows a normal sinus rhythm and chest x-ray demonstrates mild cardiomegaly with bilateral pleural effusions. You decide she needs further workup, so you call the hospital where you have admitting privileges and arrange for a telemetry bed.

1. What is the most likely diagnosis?

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