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the volume okay for you guys okay okay were gonna spend a little time talking about CHF Im sure at this point late morning many of you probably feel a little bit like this well try to keep things moving along and were going to jump right into a case just know zebras here this is not a typical case probably that you guys see every day in your emergency departments and those of you that a hospital has probably seen this occasionally unfortunately happening on the floor 65 year-old man comes in with shortness of breath thats developed over the past several hours maybe its been slowly worsening over the past day but really got bad over the past handful of hours hes got a handful of cardiac risk factors and hes looking pretty darn sick hes got a normal mental status but he is diaphoretic say febrile tachycardic tachypneic hypoxic hes extremely hypertensive like the majority these patients are and his lungs have crackles and jvd up to his ears you get a chest x-ray and in fact it c