A 64-year-old woman with diabetes mellitus and hypertension complains of slow
onset shortness of breath, weight gain, orthopnea, and bilateral leg  swelling.  

In the ED, HR 90 BP 200/100 RR 22 SpO2 91% RA.  She is in mild respiratory distress, and has rales up to half of her lung fields and bilateral pitting edema.  Her chest radiograph shows pulmonary congestion and her electrocardiogram demonstrates an R wave of 13 mm in aVL.  You decide to perform a bedside ultrasound which reveals a thickened concentric left ventricular wall, no pericardial effusion, and what appears to be a grossly normal ejection fraction.

Regarding her presentation, which of the following is the MOST likely?

A. Left ventricular failure from systolic dysfunction
B. Left ventricular failure from diastolic dysfunction
C. Right heart strain from pulmonary hypertension
D. Right heart strain from tamponade physiology


In the meantime, a few quotes – 

“Diagnosis is not the end, but the beginning of practice.” 
 
…and…

“A conclusion is the place where you got tired thinking.”

– Martin H. Fischer (1879 – 1962), German-born American physician and author