A patient presents complaining of dyspnea with exercise that worsen at night. He has to use three pillows to sleep comfortably. The most likely diagnosis is which of the following?

• A. Pneumonia
• B. Mitral valve disease
• C. Chronic heart failure
• D. Atelectasis

Answer: (A)

This pattern is classic for left-sided congestive heart failure. When a patient with heart failure lies down, venous return to the heart increases. The weakened or stiffened heart can’t handle this extra preload, so left atrial and pulmonary venous pressures rise, leading to pulmonary edema and shortness of breath. That’s why orthopnea appears and why many patients need multiple pillows to sleep comfortably; the more pillows needed, the more severe the orthopnea.

Pneumonia would typically present with fever, a productive cough, and localized lung findings rather than a symptom pattern tied to posture. Atelectasis can cause dyspnea but doesn’t usually produce marked, position-dependent dyspnea requiring several pillows. Mitral valve disease can cause heart failure symptoms, but the overall presentation fits chronic heart failure best, since orthopnea and nocturnal dyspnea are hallmarks of that condition.