Shortness of Breath OSCE - Heart Failure

Diagnosis: Heart Failure

Case Overview

  • Age/Sex: 71-year-old female
  • Occupation: Retired primary school teacher
  • Setting: Emergency department / urgent clinic
  • Chief complaint: "Shortness of breath"

Patient Script

Who I Am

I'm 71, retired, I live alone and I used to be a primary school teacher.

What Brings Me In

I'm coming because I've been getting more and more breathless for the past couple of weeks and it's got worse over the last few days — I can't lie flat at night.

My Story

About two weeks ago I noticed I'm getting more tired than usual and I couldn't walk as far as I normally do. Over the last 3 days my breathlessness has got worse — I have difficulty catching my breath when I walk across the room and I have to prop myself up on pillows at night because I can't lie flat without gasping. I woke up once in the night two nights ago gasping for air (it felt like choking) which frightened me. I've also noticed my ankles have become swollen in the past week and my shoes feel tight. I think I've put on a bit of weight — maybe 3–4 kg in the last fortnight.

I had a bit of a cough about 10 days ago that sounded chesty and the doctor gave me a course of antibiotics, but I finished that and I'm not feverish now. I sometimes get a tightness in my chest if I climb stairs but it usually goes away. I've had a couple of times when my heart felt like it was skipping or pounding, but that doesn't last long. My knees ache because of arthritis and I take occasional pain tablets for that.

My Medical Background

  • Type 2 diabetes mellitus (diagnosed 15 years ago)
  • Hypertension
  • Hyperlipidaemia
  • Chronic kidney disease stage 3 (baseline creatinine slightly raised)
  • Osteoarthritis in knees
  • Medications: metformin 500 mg twice daily, gliclazide 5 mg once daily, lisinopril 10 mg once daily, amlodipine 5 mg once daily, simvastatin 20 mg at night, paracetamol PRN, occasional over-the-counter NSAID for knee pain (rare)
  • Allergies: none known
  • Social: lives alone; ex-smoker (stopped 10 years ago, 20 pack-years); drinks 1–2 glasses of wine per week
  • Family: father had a heart attack at 70

What I Think & Worry About

  • I think I might have a chest infection because of the cough I had.
  • I'm worried I might be having a heart problem — I'm frightened I might not get better and won't be able to live on my own.
  • I want to know if this is something that needs a hospital stay or if I can go home and be looked after.

If You Ask Me About Other Symptoms...

  • Breathlessness: "It comes on with walking a short distance and I need to sleep propped up — worse at night."
  • Cough: "Had a cough that was a bit chesty and greenish, doctor gave antibiotics 10 days ago — now it's mostly gone." (no fevers since)
  • Chest pain: "Sometimes a tight feeling up my chest when I climb stairs, but it goes away quickly." (not severe)
  • Palpitations: "I get the odd fluttering or pounding, but it only lasts a minute or two."
  • Legs: "Both ankles are swollen, worse at the end of the day. My knees hurt from arthritis, but the swelling is new."
  • Dizziness/syncope: "No fainting, just more tired than usual."
  • Urine: "Urination is about the same, I have some numbness in my feet from diabetes."
  • Recent travel/immobility: "No long trips, I get up and about at home."
  • Medications: "I take my pills most days, but I sometimes take an over-the-counter painkiller for my knees when they hurt."

Clinical Summary

Examination

  • General: appears older, mildly distressed by breathlessness when speaking in full sentences
  • Vitals: temperature 36.8°C; heart rate 102 bpm (sinus tachycardia); blood pressure 158/92 mmHg; respiratory rate 24/min; SpO2 92% on room air
  • JVP: elevated to ~5 cm above sternal angle when semi-recumbent
  • Cardiovascular: displaced apex beat laterally; soft S3 gallop present; no loud murmurs, no pericardial rub
  • Respiratory: bibasal crackles, more prominent at the lung bases, no focal bronchial consolidation; small bilateral pleural effusions suspected
  • Abdomen: soft, non-tender, no hepatomegaly
  • Extremities: pitting peripheral oedema to the mid-shin bilaterally; no calf tenderness or unilateral swelling
  • Neurological: peripheral sensory loss in feet consistent with diabetic neuropathy

Investigations

  • CBC: Hb 11.6 g/dL, WCC 8.5 x10^9/L, platelets 250 x10^9/L (no leukocytosis)
  • U&E: Na+ 138 mmol/L; K+ 4.3 mmol/L; Creatinine 140 µmol/L (baseline ~120 µmol/L); eGFR ~45 mL/min/1.73m2
  • BNP: 1,200 ng/L (markedly elevated — supports heart failure)
  • Troponin I: 0.04 ng/mL (mildly above local reference or borderline depending on lab — may reflect strain)
  • ECG: sinus tachycardia; left ventricular hypertrophy; no acute ST-elevation
  • Chest X-ray: cardiomegaly with pulmonary vascular congestion, interstitial/ perihilar oedema and small bilateral pleural effusions
  • Echocardiogram (urgent): left ventricular dilatation with reduced systolic function; LVEF ~35%; mild functional mitral regurgitation

Diagnosis

  • Primary diagnosis: Acute decompensated systolic heart failure (reduced ejection fraction) on background of chronic ischemic/hypertensive heart disease and diabetes.

    • Evidence: progressive exertional dyspnoea and orthopnea over 2 weeks with acute worsening over 3 days; raised JVP; bibasal crackles; bilateral pitting oedema; CXR with cardiomegaly and pulmonary oedema; markedly elevated BNP; echocardiogram showing LVEF ~35%.

  • Differential diagnoses (with reasoning):

    • Community-acquired pneumonia: possible given recent productive cough and antibiotic use (red herring), but afebrile, normal WCC, CXR shows interstitial pulmonary oedema pattern rather than lobar consolidation.
    • COPD exacerbation: could cause breathlessness, history of ex-smoking is present (red herring), but exam lacks wheeze and imaging supports cardiogenic oedema; spirometry history absent.
    • Pulmonary embolism: acute dyspnoea could suggest PE (red herring), but presentation more gradual with signs of fluid overload, BNP and echo point to heart failure; no recent prolonged immobility.
    • Acute coronary syndrome causing pump failure: minor troponin rise could reflect strain; ECG lacks acute ischemic changes; ACS remains a consideration if pain or dynamic troponin rise occurs.

Management

  • Immediate/priorities in ED/inpatient:

    • Sit the patient upright and provide reassurance; oxygen to maintain SpO2 ≥ 92% (apply supplemental oxygen and monitor).
    • IV loop diuretic: give intravenous furosemide 40–80 mg (or equivalent) and monitor urine output and symptomatic response.
    • Monitor vital signs, strict fluid balance and daily weights.
    • If hypertensive and pulmonary oedema severe consider IV nitrate therapy and urgent cardiology review.
    • Avoid further NSAIDs which can worsen fluid retention and renal function; review and hold any offending medications.
    • Check serial electrolytes and renal function 6–12 hours after diuresis; adjust diuretic dose accordingly.
    • Consider non-invasive ventilation (CPAP/BiPAP) if persistent hypoxia or respiratory distress despite oxygen.

  • Short-term/ongoing management after stabilization:

    • Continue heart failure guideline-directed therapy: start/uptitrate ACE inhibitor (or ARB/ARNI where appropriate) if not contraindicated, and consider initiation of a beta-blocker once euvolaemic.
    • Assess for coronary ischemia as contributing cause; consider cardiology input for ischemic workup (stress testing or coronary angiography) if indicated.
    • Initiate or optimize secondary prevention: high-intensity statin, anti-platelet therapy if ischemic heart disease confirmed.
    • Medication review with attention to diabetic agents and renal function; consider diabetes team input.
    • Arrange early outpatient heart failure follow-up, education on low-salt diet, fluid restriction advice as needed, and adjustment of diuretics with community nursing support if required.
    • Vaccinations (influenza, pneumococcal) and smoking cessation reinforcement.

Key Learning Points

  • Acute decompensated heart failure often presents with progressive exertional dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea and peripheral oedema; elevated JVP, crackles and S3 are useful bedside signs.

  • BNP, chest radiography and echocardiography are key investigations to confirm heart failure and assess severity; management focuses on relieving congestion with diuretics, supporting oxygenation and initiating guideline-directed medical therapy once stabilized.

  • Always consider and exclude common mimics (pneumonia, COPD exacerbation, pulmonary embolism, ACS) — look for concordant clinical findings and use targeted investigations to differentiate them.

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