A 46-year-old white woman enters the emergency ward complaining of acute shortness of breath on exertion. The patient states that she has a history of both heart disease and emphysema. She was in her usual state of health until 2:30 A-M, when she was awakened by the sudden onset of severe dyspnea. There was no chest pain associated with her dyspnea; however, she did note a cough productive of pinkish sputum.

On physical examination, she is dyspneic and in obvious distress. Her blood pressure is 210/120. Her pulse is 115 and regular. Her temperature is 37 C, and her respiratory rate is 34. Her neck veins are not distended. Examination of the thorax reveals pulmonary rales up to the level of the scapulae and bilateral wheezes. The cardiac examination reveals a summation gallop and no murmurs. There is no evidence of peripheral edema. An electrocardiogram (ECG) shows normal sinus rhythm and nonspecific S-T segment changes. A chest x-ray demonstrates an enlarged heart and fluffy bilateral alveolar densities. Arterial blood gases drawn on room air reveal a Po2 of 59, a PCO2 of 25, and a pH of

(A) emphysema exacerbated by pneumonia
( B ) pulmonary embolism
(C) adult respiratory distress syndrome (ARDS)
(D) acute cardiogenic pulmonary edema
( E ) hypertensive crisis

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