Case Background

Our patient is a 36-year-old man with a chief complaint of progressive shortness of breath on exertion of two months duration.

The pertinent features of his history include the following:

A heart murmur has been heard since childhood. For several years, he has noted prominent neck pulsations while shaving, and has been told that his systolic blood pressure was elevated.

In addition to his dyspnea on exertion, for the last two months he has had nocturnal episodes of both profuse sweating without fever and dyspnea that was relieved by sitting up. He has also gained a few pounds of weight.

There was no history of chest pain, palpitations, edema, syncope or rheumatic fever.