A 31-Year-Old Man Comes to the Office Due to Progressive

A 31-year-old man comes to the office due to progressive dyspnea over the past several months.  The patient states that the shortness of breath improved initially with supine positioning, but lately, it is present even on recumbency and during minimal exertion.  He reports recurrent episodes of nosebleeds since childhood but has no other medical conditions.  Temperature is 36.7 C (98.1 F) , blood pressure is 110/50 mm Hg, pulse is 102/min, and respirations are 20/min.  Oxygen saturation is 96% on room air.  Cardiac examination reveals an accentuated S2 over the upper left sternal border.  The lungs are clear to auscultation.  There is digital clubbing.  Skin examination findings are shown in the exhibit.  Which of the following is the most likely underlying cause of this patient's dyspnea?

A) Airway obstruction
B) Endocardial infection
C) Pulmonary fibrosis
D) Valvular dysfunction
E) Vascular malformation

Correct Answer:

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