A 61-year-old retired physician presents with a 6-month history of worsening midepigastric bloating sensation associated with fatigue, diarrhea, and lower extremity edema. He has occasional episodes of heat intolerance and has had a 15-lb weight loss.

Physical examination reveals a thin, fatigued, chronically ill-appearing 61-year-old man in no acute distress. Blood pressure is 110/60 mm Hg, pulse is 90 beats per minute, and respiratory rate is 18 breaths per minute. Neck veins are elevated to the level of the jaw. Lungs are clear to auscultation. There is a right parasternal lift and a palpable right ventricular heave. There is a normal S1 and S2 with a 3/6 holosystolic murmur heard best in the left lower sternal border. Abdomen is distended with evidence of 3 mm of shifting dullness and a palpable fluid wave. There is 3+ pitting edema extending to the midthigh (Fig. 45-1 and Videos 45-1 to 45-7).