CASE PRESENTATION A 67-year-old Caucasian woman was admitted to our hospital with progressive shortness of breath and swelling of all four extremities. Her past medical history included type 2 diabetes and hypertension of approximately 20 and 10 years of duration, respectively, hypothyroidism, morbid obesity, paroxysmal atrial fibrillation, and sciatica. She denied a history of diabetic nephropathy or retinopathy. On questioning, she noted that over the previous 4 months she had developed new onset of lower extremity edema, increasing abdominal girth, and approximately 60 lb weight gain. More recently over the 3 weeks before admission, she had developed new onset of orthopnea and dyspnea with minimal exertion. She denied any recent history of chest pain, fever, foamy urine, or leg pain. Medications at the time of admission included lopressor 50 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 50 mg daily, furosemide 40 mg daily, repaglinide 2 mg daily, rosiglitazone 8 mg daily, gabapentin 200 mg twice daily, and levothyroxine 200mg daily. Except for the gabapentin, which had been added 3 weeks before admission for her sciatica, she had been on stable dosing of her other medications for the previous several months. Rosiglitazone had been added approximately 36 months before the current presentation. The prescribing physician had not recorded a baseline weight at that time. She had not been treated with insulin for her diabetes, and she had not taken any non-steroidal anti-inflammatory agents in the previous few months. Pulse oximetry revealed an oxygen saturation of 90% while breathing room air, which increased to 100% while breathing supplemental oxygen at a rate of 2 l/min. She was afebrile, and her blood pressure was 120/70 mm Hg. On examination, she was anxious, visibly short of breath, and unable to complete full sentences. She was markedly obese. She had crackles in both lung fields up to the apices. She had deep pitting edema of the arms, legs, anterior abdominal wall, and pre-sacral areas. Heart sounds were distant. Examination of the head and neck, skin, and joints and lymph nodes was unremarkable. Electrocardiogram showed sinus tachycardia at a rate of 100 bpm. Portable chest X-ray (CXR) showed cardiomegaly and perihilar edema consistent with congestive heart failure (Figure 1). Ultrasound of the lower extremities showed no evidence of deep venous thrombosis and a ventilation-perfusion (V/Q) scan showed no evidence of pulmonary embolism. Patient laboratory data are indicated in Table 1.