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Mr. J. is a 70 year old retired accountant who was discharge…

Mr. J. is a 70 year old retired accountant who was discharged from the hospital three months ago following treatment for a myocardial infarction. He was able to resume light activity at home. Approximately one month ago, he began to experience occasional exertional dyspnea and fatigue. Presently, he feels tired and short of breath while climbing one flight of stairs. He is able to work in his garden for only 15-20 minutes before becoming tired and short of breath. He sleeps comfortably on two pillows. He denies chest pain, cough, anorexia, nausea, or edema.His physical exam reveals that Mr. J. appears anxious. Vital signs: BP 107/70, P 94 and Reg., Resp 22, wt 150, a gain of 6 pounds from the previous month. On examination of his eyes, his conjunctiva are clear, sclera white and lenses moderately opaque. His fundi are not visualized. With Mr. J. resting at a 45 degree angle, his neck veins are at the level of the sternal angle and do not rise upon deep palpation of the liver. His breath sounds are decreased in both bases with crackles heard bilaterally. His apical impulse is accentuated and visible at 15 cm lateral to his mid-sternal line. On auscultation, S1 and S2 are distant with an extra low-pitched heart sound early in diastole heard at the apex. Mr. J’s abdomen is non-tender. There are no palpable organs or masses. His peripheral pulses are all 2+ and there is 1+ ankle edema.Exertional dyspnea and fatigue may be related to prolonged inactivity and weight gain, but with Mr. J’s history and physical findings, you should be especially suspicious of:

An 18 yr old male comes to the ER with c/o sudden onset of S…

An 18 yr old male comes to the ER with c/o sudden onset of SOB and chest pain. He denies injury, illness or cough. Percussion hyperresonant, fremitus absent, breath sounds NOT audible over Right chest, RR 32. The Left chest is normal. The most likely diagnosis is: