A 74-year-old man who is a chronic smoker presents with fatigue and shortness of breath. He has not seen a physician for many years and says he has been basically healthy.
On physical examination, he is found to be pale, mildly cachectic, and his lips are cyanotic.
His breath sounds are distant, although crackles can be heard in both lung bases. His heart sounds are best heard in the epigastrium; and a third heart sound is present. He has mild peripheral edema.
His resting pulse oximetry is 74%.
The chest X-ray (CXR) shows emphysema and his echocardiogram confirms heart failure.
The X Ray is shown below: