Left heart failure may present with progressive dyspnea on exertion. Paroxysmal nocturnal dyspnea is an even more classic symptom. His modest weight gain could also relate to fluid retention from congestive heart failure.

The patient's history also provides clues to the etiology and severity. A congenital valvular or shunt lesion is suggested by the history of a heart murmur since childhood.

The lesion is probably severe, as systolic hypertension and prominent pulsations in the neck, likely from his carotid arteries, are consistent with a large stroke volume.

Night sweats, likely related to autonomic dysfunction, also suggest that the lesion is severe.