Jesse is a 57-year-old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and occasional epigastric pain. He states that at night he has trouble breathing especially while lying on his back. This is relieved by him sitting up. His vitals are 180/110, P = 88, T = 98.0 F, R = 20.

Write a differential in this case and explain how each item in your differential fits and how it might not fit.

What tests would you order? What immediate treatment would you consider giving this patient and what treatment when he went home? Assume your first differential is definitive.

Now, he comes back to your clinic 3 months later and both his ankles are slightly swollen. What possible explanations are there for this observation?