Buat pengkajian dan membahas kasus ini, pemeriksaan diagnostik, diagnosa pasien, rencana tindak

lanjut.
No. 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 S 1 and a second heart sound that splits during expiration, an S 4 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?

 A 37-year-old executive returns to your clinic for follow-up of recurrent upper

abdominal pain. He initially presented 3 weeks ago, complaining of an increase
in frequency and severity of burning epigastric pain, which he has experienced
occasionally for more than 2 years. Now the pain occurs three or four times per
week, usually when he has an empty stomach, and it often awakens him at
night. The pain usually is relieved within minutes by food or over-the-counter
antacids, but then recurs within 2 to 3 hours. He admitted that stress at work
had recently increased and that because of long working hours, he was
drinking more caffeine and eating a lot of take-out foods. His medical history
and review of systems were otherwise unremarkable, and, other than the
antacids, he takes no medications. His physical examination was normal,
including stool guaiac that was negative for occult blood. You advised a change
in diet and started him on a proton-pump inhibitor. His symptoms resolved
completely with the diet changes and daily use of the medication. Results of
laboratory tests performed at his first visit show no anemia, but his serum
Helicobacter pylori antibody test was positive.
What is your diagnosis?
What is your next step?