Medical Surgical Nursing Case Study: Cardiovascular System 1

A 72-year-old man presents to the clinic complaining of several weeks of worsening exertional dyspnea. Previously, he had been able to work in his garden and mow the lawn, but now he feels short of breath after walking 100 feet. He does not have chest pain when he walks, although in the past he has experienced episodes of retrosternal chest pressure with strenuous exertion. Once recently he had felt lightheaded, as if he were about to faint while climbing a flight of stairs, but the symptom passed after he sat down. He has been having some difficulty sleeping at night and has to prop himself up with two pillows. Occasionally, he wakes up at night feeling quite short of breath, which is relieved within minutes by sitting upright and dangling his legs over the bed. His feet have become swollen, especially by the end of the day. He denies any significant medical history, takes no medications, and prides himself on the fact that he has not seen a doctor in years. He does not smoke or drink alcohol.

On physical examination, he is afebrile, with a heart rate of 86 bpm, blood pressure of 115/92 mm Hg, and respiratory rate of 16 breaths per minute. Examination of the head and neck reveals pink mucosa without pallor, a normal thyroid gland, and distended neck veins. Bibasilar inspiratory crackles are heard on examination. On cardiac examination, his heart rhythm is regular with a normal S1 and a second heart sound that splits during expiration, an S4 at the apex, a nondisplaced apical impulse, and a late-peaking systolic murmur at the right-upper sternal border that radiates to his carotids. The carotid upstrokes have diminished amplitude.

What is the most likely diagnosis?

What test would confirm the diagnosis?