Jоhn is а 66 yeаr оld mаle whо presented to the emergency department with new onset shortness of breath which began two weeks ago but has worsened over the last 24 hours. He has slept sitting up on the sofa for the past two nights. He denies chest pain or tightness, fever or chills, and had no recent sick contacts. He reports his legs have some new “swelling” and his shoes are too tight. His PMH includes HTN, Diabetes, hyperlipidemia and arthritis Medications at home are: Amlodipine 5 mg daily, Simvastatin 20 mg daily, Metformin 500 mg BID, and Naprosyn. He has recently refilled his medications and generally takes as prescribed. You are the NP working on the internal medicine service and you get called to evaluate John. On exam you find he is awake, alert and oriented. You note he was markedly dyspneic when he ambulated 20 feet, but after returning to a chair, he is breathing comfortably at rest. His neck veins are distended. His heart rate is regular. His lungs are generally clear bilaterally but you note they are decreased at the bases. His extremities are warm but he has +2 bilateral pedal and pre-tibial pitting edema. Vital signs are: Temp 97.7, HR 98, RR 26, BP 159/82