<s>[INST] context: A hepatojugular reflux indicates liver congestion caused by the backup of blood into the venous circula­tion, secondary to problems in the right heart (e.g., right-sided heart failure, tricuspid stenosis, tricuspid regurgitation)
An S3 heart sound occurs during the rapid-filling phase of the ventricle in early diastole. In mitral valve incompetence and increased preload in the left ventri­cle, an S3 heart sound is an excellent indicator of ventricular failure. The increased left ventricular end diastolic pressure is reflected back into the left atrium, with a subsequent increase in the hydrostatic pressure in the pulmonary veins. When pulmonary venous pressure is greater than the pulmonary capillary on­co tic pressure, a transudate leaks first into the intersti­tium (Kerley lines on a chest radiograph) and eventu­ally into the alveoli, resulting in pulmonary edema and congestion.
Dyspnea, or the sensation of difficult or uncomfort­able breathing, is the most common symptom of left sided heart failure. When a patient with left-sided heart failure lies down, the reduced gravitational force increases venous return to the heart. Because the left ventricle cannot handle the increased load, the blood backs up into the lungs, producing dyspnea. Paroxys­mal nocturnal dyspnea specifically refers to a choking sensation that wakens the patient at night. It usually subsides) to 20 minutes after the patient stands up, opens the window, and takes deep breaths.
Another finding associated with left-sided heart fail­ure is reduced renal perfusion, which occurs during the day due to the decreased cardiac output. Reduced cardiac output decreases the effective arterial blood volume and the glomerular filtration rate, allowing a greater reabsorption of urea in the proximal tubule. Because creatinine is neither reabsorbed nor secreted in the tubules, a reduction in the glomerular filtration rate causes a minor increase in serum creatinine. The disproportionate increase in the blood urea nitrogen level over that of the serum creatinine is called prerenal azotemia. [/INST] question: Which one of the following finding is Not associated with left-sided heart failure? | options: A: Pulmonary edema B: Hepatojugular reflux C: Paroxysmal nocturnal dyspnea D: Prerenal azotemia | answer: B </s>