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, weight gain, orthopnoea or waking up breathless at night.
This station is testing:
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Does this sound like heart failure?
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How severe are the symptoms?
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Is there fluid overload?
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What might have caused or triggered it?
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Is the patient stable or acutely unwell?
OSCE Talk Tip
Heart failure histories are about two big questions:
How breathless are they?
Are they overloaded with fluid?
So do not just ask, “Are you short of breath?”
Ask how far they can walk, whether they can manage stairs, whether they are breathless lying flat, whether they wake up gasping, and whether their ankles or weight have changed.
That gives you the heart failure pattern.
What this Station is Testing?
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Explore breathlessness and exercise tolerance
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Symptoms of fluid overload eg: orthopnoea and PND
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Causes of heart failure eg: previous MI, hypertension, valvular dysfunction
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Impact on activities of daily living
Explore Breathlessness using OPERA
Breathlessness is usually the main symptom in a heart failure history, so OPERA works well.
ONSET
“When did the breathlessness start?”
“Did it come on suddenly or gradually?”
Gradual breathlessness over weeks or months can fit chronic heart failure. Sudden severe breathlessness should make you think about acute pulmonary oedema, PE, ACS, pneumonia or another acute cause.
PROGRESSION
“Has it been getting better, worse or staying the same?”
“Is there anything you could do before that you can’t do now?”
Worsening breathlessness or a clear drop in exercise tolerance suggests progression.
EXACERBATING & RELIEVING FACTORS
“What brings the breathlessness on?”
“Is it worse when walking, climbing stairs or lying flat?”
“What helps it settle?”
Heart failure breathlessness is often worse on exertion or lying flat and improves with rest or sitting upright.
ASSOCIATED SYMPTOMS
Ask about orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling, weight gain, fatigue, chest pain, palpitations, syncope, cough, wheeze, fever and infective symptoms.
Assess Exercise Tolerance and Severity
Exercise tolerance is one of the most important parts of a heart failure history.
Ask:
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“How far can you walk on the flat before you have to stop?”
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“Can you manage stairs?”
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“Can you walk around the house?”
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“Can you get to the shops?”
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“How does that compare to normal for you?”
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“Are you breathless at rest?”
A patient who used to walk to the shops but is now breathless around the house has had a significant decline.
Ask about Orthopnoea, PND and Fluid Overload
Ask about orthopnoea:
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“Do you get short of breath when lying flat?”
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“Have you had to use more pillows at night?”
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“Has that changed recently?”
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Ask about paroxysmal nocturnal dyspnoea:
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“Do you ever wake up suddenly at night feeling short of breath?”
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“What do you have to do when that happens?”
Patients may describe waking up gasping, sitting upright, opening a window or needing several minutes before settling again.
Ask about fluid overload:
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“Have you noticed swelling in your ankles or legs?”
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“When did it start?”
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“Is it getting worse?”
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“How far up the legs does it go?”
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“Is it both legs or one leg?”
Also ask about weight gain, abdominal swelling, reduced appetite and reduced urine output where relevant.
Think Left-Sided and Right-Sided Heart Failure
A simple way to think about symptoms is:
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.
Ask about Cardiac Symptoms, Causes and Triggers
Heart failure may be caused or worsened by other cardiac problems.
Ask:
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“Have you had any chest pain?”
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“Have you noticed your heart racing or beating irregularly?”
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“Have you had any dizziness, faints or funny turns?”
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Then look for causes and triggers:
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Previous MI or angina
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Hypertension
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Atrial fibrillation
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Valve disease
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Cardiomyopathy
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Kidney disease
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Recent infection
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Recent medication changes
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Missed medications
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Excess salt or fluid intake
These questions help you work out why heart failure developed or why it may have suddenly worsened.
Acute heart failure red flags
Most OSCE heart failure histories are about chronic symptoms, but you should recognise acute decompensation.
Concerning features include:
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Severe breathlessness at rest
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Hypoxia
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Pink frothy sputum
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Chest pain
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Syncope or pre-syncope
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New confusion or agitation
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Cold, clammy peripheries
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Rapid deterioration
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Hypotension or shock
These features should prompt urgent assessment and escalation.
Past Medical and Surgical History
Ask about general medical history, then focus on conditions relevant to heart failure.
Look out for:
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Previous MI or angina
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Hypertension
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High cholesterol
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Diabetes
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Atrial fibrillation
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Valve disease
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Cardiomyopathy
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Stroke or TIA
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Chronic kidney disease
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COPD
Also ask about coronary stents, bypass surgery, valve surgery, pacemaker or ICD.
If there has been a recent MI, ask when it happened, what treatment they had and whether they were told how well the heart was pumping.
Drug History and Allergies
Ask about regular medications, over-the-counter medication and allergies.
In heart failure, focus on:
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Medication adherence
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Recent medication changes
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Water tablets, such as furosemide or bumetanide
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Heart medications started after MI
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NSAIDs, such as ibuprofen or naproxen
Useful questions include:
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“Are you taking your medications as prescribed?”
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“Have any doses changed recently?”
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“Are you on water tablets?”
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“Are you taking anti-inflammatory tablets like ibuprofen or naproxen?”
NSAIDs can worsen fluid retention, so they are important to ask about.
Family History
Ask about family history of heart failure, heart attacks, valve disease, cardiomyopathy or sudden cardiac death.
If there is a family history, clarify who was affected, their age and what happened.
Social History & Functional Impact
In heart failure, social history should focus on function, independence and safety at home.
Ask:
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“Who is at home with you?”
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“How are you managing day to day?”
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“Can you manage stairs, shopping, washing, dressing and cooking?”
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“Is this affecting your sleep, work or independence?”
Also ask about smoking, alcohol, diet, salt intake and fluid intake where relevant.
Heart failure can be frightening, especially if the patient is waking up breathless at night, so acknowledge the impact.
Ideas, Concerns and Expectations
Ask naturally:
“Had you any thoughts yourself about what might be causing this?”
“Is there anything in particular you’re worried about?”
“What were you hoping we might be able to do today?”
If the patient is frightened, acknowledge it:
“I can understand why this would feel frightening, especially if you’re waking up short of breath at night. We’ll take this seriously and work out the next steps.”
Example Summary:
“Mr Jones is a 72-year-old man presenting with a three-month history of gradually worsening breathlessness on exertion, reduced exercise tolerance and bilateral ankle swelling. He previously could walk to the shops but now becomes breathless walking around the house. He also describes orthopnoea, now requiring three pillows at night, and episodes of waking suddenly short of breath. He denies chest pain, syncope, fever or infective symptoms. His past history includes hypertension and a previous myocardial infarction. Overall, this history is concerning for heart failure, and I would want to examine him, check observations, arrange blood tests including NT-proBNP, perform an ECG and request an echocardiogram.”
NYHA Classification
NYHA classification describes how limited someone is by heart failure symptoms:
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Class I: no limitation of ordinary activity
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Class II: symptoms with ordinary activity
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Class III: symptoms with less than ordinary activity
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Class IV: symptoms at rest
In an OSCE, it is usually more useful to ask about walking distance, stairs, shopping and breathlessness at rest than to quote the class.
Heart Failure Medications
For heart failure with reduced ejection fraction, students often hear about the “four pillars”:
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ACE inhibitor, ARB or ARNI
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Beta-blocker
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Mineralocorticoid receptor antagonist
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SGLT2 inhibitor
Loop diuretics, such as furosemide or bumetanide, help symptoms when the patient is fluid overloaded.
In a history station, focus on adherence, recent changes, diuretics and medications that may worsen heart failure.
Possible Examiner Questions & Model Answers
Q1: What are your top differential diagnoses?
My main concern would be heart failure.
Other causes of breathlessness include COPD, asthma, pneumonia, pulmonary embolism, anaemia, arrhythmia and acute coronary syndrome
Q2: What features make you concerned about heart failure?
Exertional breathlessness, reduced exercise tolerance, orthopnoea, PND, ankle swelling, weight gain, fatigue, previous MI, hypertension, atrial fibrillation, valve disease and symptoms progressing over weeks or months.
Q3: What is orthopnoea?
Orthopnoea is breathlessness when lying flat.
Patients may describe needing extra pillows or sleeping upright.
Q4: What is paroxysmal nocturnal dyspnoea?
Paroxysmal nocturnal dyspnoea is sudden breathlessness that wakes the patient from sleep.
Patients may describe waking up gasping and needing to sit upright for several minutes.
Q5: What examinations would you perform?
I would perform a cardiovascular and respiratory examination.
I would look for heart rate and rhythm, blood pressure, oxygen saturations, raised JVP, displaced apex beat, murmurs, basal crackles, peripheral oedema, sacral oedema if bedbound and signs of poor perfusion if acutely unwell.
Q6: What investigations would you request?
Initial investigations may include ECG, chest X-ray, bloods including FBC, U&Es, LFTs, CRP, thyroid function, HbA1c and lipids where relevant, NT-proBNP, troponin if ACS is possible, and echocardiogram.
NT-proBNP can support the diagnosis, but echocardiography is needed to assess cardiac structure, valves and ejection fraction.
Q6: What might you see on chest X-ray?
Chest X-ray features can include cardiomegaly, pulmonary oedema, upper lobe diversion, Kerley B lines and pleural effusions.
Q6: How would you manage this patient?
If stable, I would arrange further assessment and investigations, treat fluid overload if present, optimise heart failure medications where appropriate, address triggers and arrange heart failure follow-up.
If acutely unwell, I would assess using ABCDE, sit the patient upright, give oxygen if hypoxic, get senior help, obtain IV access, perform ECG and chest X-ray, take bloods and consider IV diuretics according to local guidance.
Quick Heart Failure History Structure
A focused heart failure history can be structured around:
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Explore breathlessness using OPERA
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Assess exercise tolerance
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Ask about orthopnoea and PND
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Ask about fluid overload
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Ask about chest pain, palpitations and syncope
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Consider causes and triggers
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Cover PMH, drugs, family history and social history
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Explore ICE
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Summarise and suggest examination or investigations if asked
Key Message
A strong heart failure history is about recognising the pattern.
Ask about breathlessness, exercise tolerance, orthopnoea, PND, fluid overload, causes, triggers and impact on daily life.
In an OSCE, this shows you are assessing severity, risk and function — not just collecting symptoms.