Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “… And you may ask yourself … well, how did I get here? ... And you may tell yourself … my God! What have I done?" -David Byrne A 92 year old woman is transferred to the coronary care unit for treatment of pulmonary edema. She was initially admitted to the hospital one week prior from a rehab facility for treatment of pneumonia. On initial presentation she was given 2 litres of saline, vancomycin and piperacillin-tazobactam 4.5 grams every 6 hours. Over the course of 5 days, her inflammatory symptoms improved, however her intake was diminished and she was placed on 75 mL/hour of 0.9% saline. For 48 hours prior to transfer to the CCU she was notably more short of breath and displayed evolving lower extremity edema. 3 months ago, her transthoracic echocardiogram demonstrated a normal ejection fraction with an E/e’ of 16, dilated left atrium and an elevated RVSP. The floor team placed her on fluid restriction and standing IV furosemide. In the CCU, she was noted to have persistent bilateral notable LE edema, bilateral B-lines and pleural effusions on lung ultrasound; as well, she had a serum sodium of 159 mmol/L.