question: Q:A 68-year-old man comes to the emergency department because of a 1-week history of worsening bouts of shortness of breath at night. He has had a cough for 1 month. Occasionally, he has coughed up frothy sputum during this time. He has type 2 diabetes mellitus and long-standing hypertension. Two years ago, he was diagnosed with Paget disease of bone during a routine health maintenance examination. He has smoked a pack of cigarettes daily for 20 years. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 25/min, and blood pressure is 145/88 mm Hg. Current medications include metformin, alendronate, hydrochlorothiazide, and enalapril. Examination shows bibasilar crackles. Cardiac examination shows a dull, low-pitched sound during late diastole that is best heard at the apex. There is no jugular venous distention or peripheral edema. Arterial blood gas analysis on room air shows:
  pH 7.46
  PCO2 29 mm Hg
  PO2 83 mm Hg
  HCO3- 18 mEq/L
  Echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is the most likely underlying cause of this patient’s current condition?"? 
  {'A': 'Destruction of alveolar walls', 'B': 'Decreased myocardial contractility', 'C': 'Diuretic overdose', 'D': 'Systemic arteriovenous fistulas', 'E': 'Impaired myocardial relaxation'},