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A woman in her early 70s with a history of hypertension and chronic obstructive pulmonary disease (COPD) was admitted to the hospital with refractory epistaxis, several months of progressive weight gain and dyspnoea. On physical examination, haemoglobin oxygen saturation by pulse oximetry was 82% on room air. The jugular venous pressure was elevated to 20 cm H20 with prominent a-waves. Cardiac auscultation revealed a prominent loud pulmonic component of the second heart sound (P2), a 3/6 holosystolic murmur at the left lower sternal border and an early, high-pitched 2/4 decrescendo diastolic murmur at the left upper sternal border. Both murmurs augmented with inspiration. There were no focal findings on pulmonary examination.