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You are a junior doctor in clinic. Mr Ollie Guria is a 58 year old man who presents with increasing breathlessness. His current Medications include: - Atorvastatin - Ramipril - Furosemide

Please take a history from Mr Guria, focusing on his presenting complaint, and perform an appropriate examination. You will then be asked to summarise your findings, present a differential diagnosis and discuss the case with the examiner.

HPC – You are Ollie Guria, a 58-year-old chap who loves football and is an avid fan of Newcastle United. Haway the lads! You enjoy nothing better than a Saturday down the Toon with the lads, drinking a few pints of Brown Ale and betting on the dogs in the evening. You have come to clinic due to worsening breathlessness over the last 2 months. The first thing you noticed was that you were struggling when walking down the street to the pub, and doing big shops on a Saturday in the square. It has been getting harder over this period where you had to stop and rest during shopping, now your wife does it for you. You can still get around your house but struggle to walk far without getting breathless.

You have found that when you get breathless, you begin to cough and often bring up pink foamy stuff during particularly bad coughing fits. This happens while lying flat in bed, so you have recently started using three pillows to sleep. You thought about getting one of those fancy mattresses that massages your back and lifts you off the bed, but you’d be worried that it’d be so soft you’d never want to get out of bed!

Yesterday you fainted while cleaning the house. You felt dizzy all of a sudden and felt you needed to sit down, but fell and lost consciousness briefly before you could get to the sofa. No one saw this. You came round quickly but felt ‘rough’ and fatigued afterwards. You don’t think you hit your head, and didn’t bite your tongue. You don’t remember hitting the floor. Your wife found you on the sofa while you were recovering and you felt quite embarrassed about it. You hate showing any weakness. You have had a couple of episodes in the past week where you have woken suddenly during the night feeling like you are unable to breathe. This passes quickly however and you are able to get back to sleep. These episodes feel super scary though – it’s like you’re waking up from a nightmare!

PMH – Your doctor noticed you have a ‘Heart Murmur’ last year and have had to see him regularly ever since. Luckily, you share the same taste in football teams and enjoy a good chat. He’s a good lad. You had been feeling increasingly dizzy, and this has been getting worse since your problems with breathlessness.

You also take medications for high blood pressure, which you have been on since. You have also been advised to lose weight.

FH – Your dad died of a sudden heart attack ‘in his 50’s’, younger brother has diabetes.

DH - A statin, blood pressure medication (one of which makes you need the toilet more since starting). No known drug allergies.

SH – You have recently decided to quit your job as a bus driver due to your ‘dizzy spells’ over the last year as you don’t feel safe driving anymore. You live with your wife, Polly, who works as a secretary at a local law firm. She has had to do more around the house recently as well as the shopping. You feel bad, because she does so much already. You realise that you are really lucky to have her in your life. You have two boys who have recently moved out. You smoke 20 a day and have since you were 18. You used to drink several pints on weekends with your friends, but struggle to get out as much now.

ICE – You think it has something to do with your bad heart. Your wife has had to do more and more of your daily activities and you are concerned that if you don’t get better she will have to give up her job to take care of you full time and that you are increasingly becoming a burden on her. You expect to get medication that will help you get around better.

A Cardiovascular examination would be appropriate in this case, however a Respiratory exam to could also be justified to rule out other causes of breathlessness.

A reasonable differential diagnosis would sound something like:

“My main differential diagnosis would be a cardiovascular cause: more specifically Heart Failure. This is due to the progressively worsening dyspnoea, frothy pink sputum, postural nocturnal dyspnoea and reduced exercise tolerance on the background of multiple cardiac risk factors, such as hypertension and smoking. An alternative diagnosis would be a respiratory cause: namely COPD. This could be argued as a differential due to the sputum, chronic breathlessness and smoking history.”

Possible questions for discussion may include: • How would you investigate this patient? • What differences could be found between Left and Right Side Heart Failure? • What are the possible causes of Heart Failure? • How would you manage Heart Failure? • Which drug classes should be avoided or stopped in Heart Failure? • Are you aware of any staging classifications of Heart Failure? • Which Health Professionals may be involved in the care of this patient in the future?