Question

A 68yo man, with a history of COPD and 57-pack-year history of smoking, presents to the office with worsening shortness of breath on exertion, dizziness, and leg swelling over the past 6-months. He states that his inhalers don’t seem to be helping as much and he is finding it more and more difficult to walk without getting breathless. He denies orthopnea, paroxysmal nocturnal dyspnea, or increased cough. Vital signs show BP-157/98 mmHg, HR-88 bpm, RR-23 bpm, O2-90% on room air, and temp-98.9o. Physical examination reveals (+) JVD, widened split S2, 1+ pitting edema of the legs to the knee, and hepatomegaly. EKG is below.

1. What does the EKG show?
2. What is the diagnosis?
3. What is the next step in evaluation?
4. What is the definitive diagnostic study for this condition?