Heart failure Quiz: Ace Your Exams

A 71-year-old man presents to the emergency department due to shortness of breath with exertion and difficulty sleeping. The patient has experienced progressive shortness of breath over the past several weeks to the point where he can no longer walk to the bathroom without becoming winded. He has woken up multiple times per night with shortness of breath and has been propping himself up with several pillows to sleep. Past medical history includes hypertension, hyperlipidemia, diabetes, a 25-pack-year smoking history, and heart failure (ejection fraction 14%). He is adherent to prescribed medications, including furosemide. Temperature is 36.1°C (97.0°F), pulse is 101/min, respirations are 24/min, blood pressure is 101/82 mmHg, and O2 saturation is 90% on room air. Physical examination demonstrates an additional heart sound heard just after S2, jugular venous distension, diffuse rales on auscultation of the lungs, and pitting edema of the lower extremities. Which of the following findings is most likely present in this patient?