History Taking · Intermediate · Cardiovascular

Shortness of Breath and Ankle Swelling in a 71-Year-Old Man

Practise this PLAB 2 history taking station on Heart Failure. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the Heart Failure Clinic. Mr Robert Malcolm, a 71-year-old man, has been referred because of progressive shortness of breath and ankle swelling over the past six weeks. He had a heart attack three months ago which was treated with a stent. He attends alone. Please take a focused history, explore his understanding of his heart attack and recent symptoms, and discuss the diagnosis and management plan.

Background notes: PMH: MI 3 months ago (LAD stent), Hypertension, Type 2 diabetes, Hypercholesterolaemia

What this station tests

  • Recognising the clinical syndrome of decompensating heart failure post-MI: orthopnoea, PND, bilateral oedema, weight gain, nocturia, and dry cough as a cluster rather than isolated symptoms
  • Identifying the management gap: no diuretic prescribed despite clear fluid overload, and subtherapeutic ACE inhibitor and beta-blocker doses
  • Explaining heart failure in plain language without causing panic: addressing the alarming term while providing genuine hope about treatment response
  • Balancing history taking and counselling within a single 8-minute station: transitioning from data gathering to explanation without running out of time
  • Eliciting and addressing the fear of sudden death linked to his father's MI at 58

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Combined history and counselling stations require deliberate time allocation: spend no more than 4 minutes on history, then transition to explanation and planning. Mr Malcolm is 71, three months post-anterior MI with LAD stent, referred to the Heart Failure Clinic with progressive breathlessness and ankle swelling over six weeks. Open with: 'I understand you've been having some new symptoms since your heart attack. Can you tell me what's been happening?' He is tired, frustrated, and worried his heart has not recovered.

Core approach

The symptom cluster points to decompensating heart failure post-MI. Mr Malcolm's breathlessness started gradually, initially only on exertion (shops, stairs), now present walking on the level. He has orthopnoea (needs extra pillows), paroxysmal nocturnal dyspnoea (wakes gasping), and a dry cough worse at night. Ask about palpitations: he feels his heart racing sometimes, raising possible AF as a complication. Ankle swelling is bilateral, worse by evening, with deep sock marks. He has gained 5kg in six weeks. Nocturia has worsened to 2 to 3 times nightly. Together these features indicate NYHA class II to III heart failure.

Check his medications: aspirin, ticagrelor, ramipril (dose uncertain), bisoprolol (dose uncertain), atorvastatin 80mg, metformin. The critical gap: he is on no diuretic despite clear fluid overload, and his ACE inhibitor and beta-blocker are likely subtherapeutic. Ask about cardiac rehab: he attended 4 to 5 sessions then stopped, believing he was cured. He now regrets this.

Transition to counselling. Explain heart failure in plain language: 'The heart attack damaged some of the muscle in your heart, so it is not pumping as strongly as it needs to. The fluid causing your breathlessness and swollen ankles is building up because the heart cannot circulate it efficiently.' Use the term 'heart failure' but immediately address the alarm: 'It does not mean your heart is about to stop. It means the pumping is weaker, and we have very effective treatments to improve it.' He will react with fear. His father died of an MI at 58, and he is terrified of the same fate.

Closing and safety netting

The management plan should be concrete and hopeful. First, a water tablet (diuretic) to remove excess fluid, which should ease breathlessness and ankle swelling within days. Second, gradually increase his ramipril and bisoprolol toward target doses. Third, add new medications (spironolactone, SGLT2 inhibitor) with strong evidence for improving heart function and survival. He will ask about the diuretic worsening his nocturia: advise taking it in the morning.

Explain that heart function can improve with optimal treatment: many patients see their ejection fraction increase over months. Recommend he re-engage with cardiac rehab. Lifestyle: daily weighing (gain of 2kg in 3 days means fluid building, contact the team), salt restriction, fluid awareness. Safety net: sudden worsening breathlessness, inability to lie down, pink frothy sputum means A&E or 999. Follow-up in 2 weeks for bloods and medication uptitration. Close with genuine hope: heart failure is treatable, and most people improve significantly on the right medications.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for heart failure. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Important but balanced with counselling)

Scores well: Systematic assessment of heart failure symptoms: orthopnoea (how many pillows?), PND, ankle oedema (bilateral, timing, pitting), weight change, nocturia. Checking current medications and identifying the missing diuretic and subtherapeutic doses. Asking about cardiac rehab compliance. Asking about palpitations (possible AF complication).

Costs marks: Treating breathlessness and ankle swelling as separate problems rather than recognising the heart failure syndrome. Not checking medication doses. Not asking about cardiac rehabilitation attendance.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Clear explanation of heart failure mechanism in plain language. Concrete management plan: diuretic for immediate symptom relief, medication optimisation (uptitrate ACE-i and beta-blocker), adding MRA and SGLT2 inhibitor. Practical lifestyle advice: daily weighing with specific 2kg threshold, salt restriction, fluid guidance. Cardiac rehab re-referral. Specific safety netting for acute decompensation.

Costs marks: Vague diagnosis ('your heart is a bit weak'). No diuretic prescribed. No mention of medication uptitration. No practical lifestyle advice. No safety netting for pulmonary oedema symptoms.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing the fear triggered by 'heart failure' proactively. Exploring his fear of dying like his father. Acknowledging his frustration at functional decline. Providing genuine hope about improvement with treatment. Addressing his concern about being a burden on Patricia. Responding to his question about prognosis honestly but optimistically.

Costs marks: Using 'heart failure' without explanation and moving on. Ignoring his emotional reaction. Not exploring his father's death. Being falsely reassuring ('You'll be fine') or overly pessimistic. Not acknowledging his regret about stopping cardiac rehab.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not asking about cardiac rehabilitation compliance. Mr Malcolm attended only 4 to 5 sessions then stopped, believing he was 'cured.' This reveals a fixable gap in his recovery, and he will express regret if you discover it. Candidates who skip exercise and rehabilitation history miss a concrete action point.
  2. Spending too long on history and leaving insufficient time for the counselling component. This is a combined station. If you spend 6 minutes on history, you will score poorly on Domain 2 because you cannot explain the diagnosis, management plan, or safety netting in 2 minutes.
  3. Using the term 'heart failure' without immediately explaining what it means and does not mean. Mr Malcolm will react with alarm ('Failing? That sounds serious'). If you do not address this reaction, he leaves the consultation terrified. Candidates who explain proactively, 'it does not mean your heart is about to stop,' score well on Domain 3.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the heart failure history in this PLAB 2 station?

Combined history and counselling stations require deliberate time allocation: spend no more than 4 minutes on history, then transition to explanation and planning. Mr Malcolm is 71, three months post-anterior MI with LAD stent, referred to the Heart Failure Clinic with progressive breathlessness and ankle swelling over six weeks. Open with: 'I understand you've been having some new symptoms since your heart attack.

What are examiners marking in this heart failure station?

Marks are won for: Systematic assessment of heart failure symptoms: orthopnoea (how many pillows?), PND, ankle oedema (bilateral, timing, pitting), weight change, nocturia. Marks are lost for: Treating breathlessness and ankle swelling as separate problems rather than recognising the heart failure syndrome. Not checking medication doses.

What is the most common mistake candidates make in this heart failure station?

Not asking about cardiac rehabilitation compliance. Mr Malcolm attended only 4 to 5 sessions then stopped, believing he was 'cured.' This reveals a fixable gap in his recovery, and he will express regret if you discover it. Candidates who skip exercise and rehabilitation history miss a concrete action point.

How do I prepare for this station if I have not managed heart failure in clinical practice?

Structure beats experience here. Focus on identifying the management gap: no diuretic prescribed despite clear fluid overload, and subtherapeutic ACE inhibitor and beta-blocker doses. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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