USMLE Step 2 - Question 21

A 68 year old female with a history of hypertension, diabetes, coronary artery disease treated with coronary artery bypass grafting 20 years ago, presents to the emergency room with increasing shortness of breath and lower extremity edema. She denies any chest pains and does not drink alcohol. Her temperature is 37.0 C, blood pressure 110/70, heart rate 110, and respirations 20. Physical examination reveals a cachectic appearance, marked jugular venous distension worse with inspiration, decreased breath sounds at the left base, pulmonary rales throughout the lung fields, a regular rhythm with an extrasystolic heart sound, hepatomegaly with ascites, and 3+ pitting lower extremity edema above the knees. ECG is normal. Laboratory studies reveal elevated AST, ALT, and total bilirubin. A hepatitis profile is normal. Which of the following is the most likely diagnosis?

A. Restrictive cardiomyopathy

B. Systolic congestive heart failure

C. Tricuspid regurgitation

D. Cardiac tamponade

E. Constrictive pericarditis