Progressive breathlessness with ankle swelling — heart failure history
PLAB 2 & PRES 3 · cardiology · medium · 8 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mr George Adeyemi, 67, has come in because he has become increasingly breathless over the past two months and his ankles have swollen. Take a focused history, explore his background and risk factors, and discuss your likely diagnosis and management plan with him.
What examiners look for
Orthopnoea and paroxysmal nocturnal dyspnoea are the highest-yield questions in a breathlessness history. "How many pillows do you sleep on?" has changed more management plans than most investigations. Progressive exertional dyspnoea with dependent oedema and weight gain over weeks, in a patient with previous myocardial infarction, is decompensating heart failure until proven otherwise — but keep COPD, anaemia, infection, pulmonary embolism and deconditioning in the differential and ask the questions that separate them. Natriuretic peptides (BNP or NT-proBNP) are the first-line blood test when heart failure is suspected in the community: a normal result makes heart failure unlikely; a raised result mandates echocardiography and specialist assessment, on a timescale guided by how high it is, per NICE. Non-adherence is usually rational. This patient skips furosemide because of urinary urgency away from home — the fix is dose timing and planning, not a lecture. Ask about adherence in every chronic disease station; it is often the decompensation trigger. Other decompensation triggers worth knowing: infection, anaemia, new atrial fibrillation, uncontrolled hypertension, high salt intake, NSAIDs, and missed medication. Baseline observations, examination (pulse, blood pressure, JVP, heart sounds, lung bases, oedema), ECG, chest X-ray and bloods including renal function and electrolytes frame the severity and the safety of diuretic therapy — creatinine and potassium must be known around ACE inhibitors and diuretics. Explain surveillance in terms patients keep: daily weights at the same time, and a simple rule — a gain of around 1.5–2 kg over a couple of days, or worsening breathlessness, means contact the team promptly rather than waiting for the next appointment. Give the number your local pathway uses where one exists; do not invent precision the patient cannot act on. His real loss is the football with his grandson. Naming the functional goal back to him is not decoration — adherence follows what the patient cares about.
Guideline references
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