A 76-year-old man comes to the office because of shortness of breath. He is presently being managed for end-stage renal disease on hemodialysis. Today, the patient states that over the past 6 months he has noted increasing difficulty breathing when he exerts himself. He is relatively sedentary but does climb a flight of stairs to his bedroom at night; he says he used to be able to do this without any problem, but now he reports he needs to stop halfway up the stairs to rest. Occasionally he has mild substernal chest pressure along with the shortness of breath. The chest pressure does not radiate and is not accompanied by nausea or diaphoresis. He has noted increased swelling in his legs. He denies any shortness of breath at rest, orthopnea, or paroxysmal nocturnal dyspnea. He denies any episodes of palpitations, lightheadedness, or syncope. He denies any cough, fever, chills, or night sweats.
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