How to take a Focused History in a Patient with Suspected Heart Failure?
Heart failure is a common OSCE history station. The patient may present with breathlessness, reduced exercise tolerance, ankle swelling, fatigue, or difficulty lying flat at night.
Heart failure does not always present as “classic heart failure” in the station. The presenting complaint may simply be shortness of breath, reduced exercise tolerance, ankle swelling, weight gain, or generally feeling more tired. It can also be difficult to know from the history alone whether breathlessness is cardiac, respiratory, or something else entirely. Leg swelling can also have many causes.
In real life, heart failure often needs further assessment, blood tests such as NT-proBNP, and an echocardiogram to confirm the diagnosis and understand the type of heart failure. But in an OSCE history, your job is to recognise the pattern and ask the key questions that make heart failure more or less likely.
A good heart failure history should help you answer four questions:
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Does this sound like heart failure?
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How severe are the symptoms?
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What might have caused it?
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Is this stable chronic heart failure or acute decompensated heart failure?
Quick Heart Failure History Structure
1. Opening and consent
2. Open question
3. Explore breathlessness using OPERA
4. Ask about exercise tolerance
5. Ask about orthopnoea and paroxysmal nocturnal dyspnoea
6. Ask about ankle swelling and fluid overload
7. Ask about chest pain, palpitations and syncope
8. Screen for possible triggers
9. Past medical and surgical history
10. Drug history and allergies
11. Family history
12. Social history and functional impact
13. Ideas, concerns and expectations
14. Summary and closing
What this Station is Testing?
In a heart failure history station, the examiner wants to see that you can:
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Explore breathlessness properly
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Assess exercise tolerance and functional limitation
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Identify symptoms of fluid overload
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Ask about orthopnoea and paroxysmal nocturnal dyspnoea
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Consider common causes such as previous MI, hypertension, valve disease and arrhythmias
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Ask about relevant medications and adherence
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Understand the impact on the patient’s daily life
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Recognise when the patient may be acutely unwell
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Summarise the case clearly
Opening the consultation
Start as you would with any history:
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Wash your hands
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Introduce yourself
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Confirm the patient’s name and date of birth
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Explain that you would like to ask some questions
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Gain consent
Example:
“Hello, my name is Matthew. I’m one of the doctors here. Could I just check your name and date of birth please?”
“Today I’d like to ask you some questions about what has brought you in and how you’ve been feeling. Is that okay?”
Start with an open question
“Can you tell me what has brought you in today?”
Then let the patient speak.
In a heart failure station, the patient may say something like:
“I’ve been feeling really short of breath when I walk.”
Or:
“My ankles have been swelling and I can’t lie flat at night.”
Once you know the main symptom, explore it properly
Explore Breathlessness using OPERA
Breathlessness is usually the main symptom in a heart failure history, so OPERA works well.
ONSET
Ask when the breathlessness started:
“When did the breathlessness start?”
“Did it come on suddenly or gradually?”
A gradual onset over weeks or months may suggest chronic heart failure. Sudden severe breathlessness may suggest acute pulmonary oedema, pulmonary embolism, ACS, pneumonia or another acute problem.
PROGRESSION
Ask whether it is getting worse.
“Has it been getting better, worse or staying the same?”
“Is there anything you could do before that you can’t do now?”
This helps you assess severity and progression.
EXACERBATING & RELIEVING FACTORS
Ask what brings it on and what helps.
“What tends to bring the breathlessness on?”
“Does it happen when you walk, climb stairs or lie flat?”
“What helps it settle?”
Heart failure breathlessness is often worse on exertion and may improve with rest.
RELEVANT ASSOCIATED SYMPTOMS
Ask about symptoms that point towards heart failure or alternative diagnoses.
Important associated symptoms include:
Orthopnoea
Paroxysmal nocturnal dyspnoea
Ankle swelling
Weight gain
Fatigue
Reduced exercise tolerance
Chest pain
Palpitations
Syncope or pre-syncope
Cough or wheeze
Fever or infective symptoms
ASSESS EXCERISE TOLERANCE
This is one of the most important parts of a heart failure history.
Do not just ask, “Are you short of breath when walking?”
Try to quantify it.
For example:
“How far can you walk on the flat before you have to stop?”
“Can you manage stairs?”
“Can you walk around the house?”
“Can you get to the shops?”
“How does that compare to normal for you?”
This helps you work out how limited the patient is.
For example, a patient who used to walk to the shops but now becomes breathless just getting out of the house has had a significant decline.
NYHA Functional Classification
The New York Heart Association classification is a way of describing how limited someone is by their heart failure symptoms.
Class I
No limitation of ordinary physical activity.
Class III
Marked limitation. Less than ordinary activity causes symptoms, but the patient is comfortable at rest.
Class II
Slight limitation. Ordinary activity causes symptoms, but the patient is comfortable at rest.
Class IV
Symptoms at rest or inability to carry out any physical activity without symptoms.
You do not need to formally quote the NYHA class in every OSCE, but asking about walking distance, stairs, shopping and symptoms at rest helps you estimate severity.
Ask about orthopnoea
Ask about Orthopnoea
Orthopnoea means breathlessness when lying flat.
Ask:
“Do you ever get short of breath when lying flat?”
“Have you had to use more pillows at night?”
“How many pillows are you sleeping with?”
A useful OSCE question is:
“Has the number of pillows changed recently?”
If someone previously slept flat but now needs four pillows, that is much more significant than someone who has always slept propped up.
Ask about Paroxysmal Nocturnal Dyspnoea
Paroxysmal nocturnal dyspnoea, or PND, is sudden breathlessness at night that wakes the patient from sleep.
Ask:
“Do you ever wake up suddenly at night feeling short of breath?”
“What do you have to do when that happens?”
Patients may describe waking up gasping, sitting upright, going to a window, or needing several minutes before they can settle again.
This can be a very frightening symptom, so acknowledge that.
For example:
“That sounds really unpleasant and frightening. I can understand why that would worry you.”
Ask about Ankle Swelling and Fluid Overload
Heart failure can cause fluid overload.
Ask:
“Have you noticed any swelling in your ankles or legs?”
“When did it start?”
“Is it getting worse?”
“How far up the legs does it go?”
“Is it both legs or one leg?”
Also ask about:
Weight gain
Abdominal swelling
Reduced appetite
Reduced urine output, if relevant
Clarifying how far the swelling goes is useful. Mild ankle swelling is different from swelling up to the knees, thighs or sacrum.
Think Left-Sided and Right-Sided Heart Failure
A simple way to think about symptoms is:
Left-sided heart failure tends to cause fluid backing up into the lungs
Right-sided heart failure tends to cause fluid backing up into the body
Left-Sided Features
Look for:
Shortness of breath
Reduced exercise tolerance
Orthopnoea
Paroxysmal nocturnal dyspnoea
Cough
Pulmonary oedema symptoms
Right-Sided Features
Look for:
Ankle swelling
Leg swelling
Raised JVP on examination
Abdominal swelling
Hepatic congestion
Ascites
In real life, patients can have features of both.
Past Medical and Surgical History
Heart failure may be caused or worsened by other cardiac problems, so ask about:
Chest pain
“Have you had any chest pain?”
This may suggest ischaemic heart disease or a recent myocardial infarction.
Palpitations
“Have you noticed your heart racing or beating irregularly?”
This may suggest atrial fibrillation or another arrhythmia.
Syncope or Pre-Syncope
“Have you had any dizziness, faints or funny turns?”
This may suggest arrhythmia, severe valve disease or reduced cardiac output.
Consider Possible Causes and Triggers
Once you suspect heart failure, think about why it has happened.
Common causes include:
Previous myocardial infarction
Ischaemic heart disease
Hypertension
Atrial fibrillation or other arrhythmias
Valve disease
Cardiomyopathy
Renal disease or fluid overload
In an acute worsening, think about triggers such as:
Infection
Acute coronary syndrome
Arrhythmia
Uncontrolled hypertension
Pulmonary embolism
Medication non-adherence
Recent medication changes
Excess salt or fluid intake
Past Medical and Surgical History
Ask generally:
“Do you have any medical conditions?”
“Have you ever been in hospital or had any operations?”
Then ask specifically about conditions that are relevant to heart failure.
If the patient has had a recent heart attack, ask:
- “When did that happen?”
- “What treatment did you have?”
- “Have the doctors told you how well your heart is pumping?”
- This may give clues about heart failure with reduced ejection fraction.
In particular, ask about:
- Previous heart attack
- Angina
- High blood pressure
- High cholesterol
- Diabetes
- Atrial fibrillation
- Valve disease
- Previous stroke or TIA
- Chronic kidney disease
- COPD or other lung disease
You may also ask about Relevant Procedures:
- Coronary stents
- Coronary artery bypass grafting
- Valve surgery
- Pacemaker or ICD
Acute heart failure red flags
Most OSCE heart failure histories are about chronic symptoms, but you should recognise when the patient may be acutely unwell.
Concerning features include:
Severe breathlessness at rest
Hypoxia
Pink frothy sputum
Chest pain
New confusion or agitation
Cold, clammy peripheries
Syncope or pre-syncope
Very rapid deterioration
Severe pulmonary oedema symptoms
Hypotension or shock
In real life, you would assess using ABCDE, sit the patient upright, check observations, give oxygen if hypoxic, get senior help, gain IV access, request an ECG and consider urgent treatment such as diuretics depending on the clinical situation.
Drug History and Allergies
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Ask generally:
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“Do you take anything over the counter or from the pharmacy?”
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“Do you take any regular medications?”
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Then ask focused questions:
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Were they started on any new medications after a heart attack?
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Are they taking their medications as prescribed
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Have any doses changed recently?
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Are they on water tablets, such as furosemide or bumetanide?
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Are they on heart failure medications, such as an ACE inhibitor, beta-blocker, MRA or SGLT2 inhibitor?
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Are they taking NSAIDs, which can worsen fluid retention?
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Have they taken anything that helped the breathlessness or swelling?
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Do not get too bogged down in every medication name. In an OSCE, the key is to ask generally, then focus on adherence, recent changes and medications relevant to heart failure.
Then ask about allergies:
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“Do you have any allergies?”
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If yes, clarify the reaction:
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“What happens when you take it?”
Explore the Patient’s Ideas, Concerns and Expectations.
Explore the patient’s ideas, concerns and expectations.
Try to make this sound natural rather than robotic.
Example Summary:
Here is an example of how you might summarise a concerning chest pain history:
“Mr Johnson is a 68-year-old man presenting with a one-hour history of central, heavy chest pain that came on while walking. The pain radiates to his left shoulder and jaw and is associated with shortness of breath and nausea. He has had similar exertional chest pain over the last few months which normally settled with rest, but this episode has not settled. His background includes hypertension and hypercholesterolaemia. He smokes heavily and has a family history of myocardial infarction. Overall, I would be concerned about acute coronary syndrome and would want to assess him urgently.”
A good summary should include:
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Who the patient is
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What the presenting complaint is
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Key positive features
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Key risk factors
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Important negatives, if relevant
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Your main concern or likely differential
For Example:
“I’ve been listening to everything you’ve said, and I can understand why this is worrying. Had you any thoughts yourself about what might be going on?”
“Is there anything in particular you’re worried this could be?”
“What were you hoping we might be able to do for you today?”
If the patient says they are worried it is their heart, acknowledge that.
For example:
“I understand why you’re worried about that. I’m taking this seriously, and I’d want to assess you urgently and do some tests to work out what is going on.”
Avoid saying:
“I’m sure it’s nothing.”
That can sound reassuring, but it may be unsafe before serious causes have been considered.
Possible Examiner Questions & Model Answers
At the end of a chest pain history, the examiner may ask you some follow-up questions. These are usually designed to test your clinical reasoning after you have taken the history.
Q1: What are your top differential diagnoses?
“My main concern would be acute coronary syndrome, including myocardial infarction or unstable angina. Other important differentials would include pulmonary embolism, aortic dissection
A strong answer should put the most dangerous and most likely diagnoses first.
Q2: What is your most likely diagnosis?
“This would depend on the history. If the patient had central crushing chest pain radiating to the arm or jaw, associated with sweating, nausea or breathlessness, especially with cardiovascular risk factors, my main concern would be acute coronary syndrome.”
Q3: How would you explore cardiovascular risk factors during the history taking?
What features make you concerned about acute coronary syndrome?
Features that would make you concerned include:
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Central heavy, tight or crushing chest pain
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Radiation to the arm, neck or jaw
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Pain brought on by exertion
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Pain not settling with rest
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Sweating
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Nausea or vomiting
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Breathlessness
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Previous angina symptoms
Cardiovascular risk factors such as smoking, diabetes, hypertension, high cholesterol or family history
A particularly concerning history is chest pain that previously came on with exertion and settled with rest, but is now more severe, lasting longer or not settling.
Q4: What investigations would you request?
“I would assess the patient urgently and start with observations, an ECG and blood tests.”
Useful investigations include:
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Full set of observations
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12-lead ECG
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Troponin, repeated according to local protocol
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Full blood count
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Urea and electrolytes
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Liver function tests
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CRP if infection or inflammation is possible
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Coagulation screen if anticoagulation or procedures may be needed
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Chest X-ray
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Consider D-dimer or CTPA if pulmonary embolism is suspected
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Consider arterial or venous blood gas if the patient is unwell or hypoxic
In an OSCE, the key investigation for suspected acute coronary syndrome is an ECG, followed by troponin testing.
Q5: What are modifiable and non-modifiable cardiovascular risk factors? Explain the features that differentiate stable angina from unstable angina.
Modifiable risk factors are things we may be able to change or improve.
Examples include:
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Smoking
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Hypertension
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High cholesterol
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Diabetes control
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Diet
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Exercise
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Alcohol intake
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Weight
Non-modifiable risk factors are things we cannot change.
Examples include:
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Age
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Sex
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Family history
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Ethnicity, depending on the population and context
Q6: How would you manage this patient initially?
“If I was concerned about acute coronary syndrome, I would treat this as an emergency. I would assess the patient using an ABCDE approach, check observations, get senior help, perform an ECG and follow local ACS guidance.”
Initial management may include:
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ABCDE assessment
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Full observations
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Urgent 12-lead ECG
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IV access and bloods, including troponin
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Pain relief
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Anti-emetic if nauseated
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Oxygen only if hypoxic
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Antiplatelet therapy if ACS is suspected and not contraindicated
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Cardiology or emergency medicine senior review
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Continuous monitoring if unstable
You do not need to give a full ACS protocol in a history station, but you should show that you recognise this could be urgent.
Key Message
A strong chest pain history is not just about asking SOCRATES.
It is about recognising risk.
Explore the pain properly, ask about associated cardiovascular symptoms, screen for serious causes, identify risk factors and respond to the patient’s concerns.
In an OSCE, that shows the examiner you are not just taking a history — you are thinking like a safe clinician.