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You are an FY1 on a GP rotation. Mrs Pamil, a 72 year old lady, has come in to see you during a routine surgery. She lives alone and is known to have hypertension, for which she sees the practise nurse, but is otherwise an infrequent attender to the surgery.
Please take a history and perform the examination you feel is appropriate. Ensure you address their concerns regarding this presentation.

You are Mrs Pamil (“Call me Vera!”), a 72 year old lady. You live alone and have done since your husband died last year. You have 4 cats, Mr Tibbles, Enid, Fang, and Blyton. You enjoy a good natter with the other ladies from Church and volunteer at the local toddler group. You used to be a baker but retired 12 years ago, now you frequently make cakes for charity. You are very chatty by nature and frequently go off topic when the doctor asks open ended questions. Don’t make it too difficult for them if they signpost clearly, but if they do not signpost, interrupt politely or steer the conversation back to the history, continue to chat about what your friends have been doing and about their various illnesses.

PC: You’ve been feeling very out of breath recently, and if the doctor asks, it’s been stopping you from going out and about in the community. It feels like you can’t quite catch your breath if you walk past the end of the road and you have to stop and rest. You’ve been struggling with the stairs at home but you are otherwise managing ok. You’re not quite sure when it started but it’s been slowly getting worse since Bert died. You’ve had no chest pain, and no cough. You sleep with two pillows at night. You’ve had no infections or illnesses recently except for the odd sniffle. You do occasionally feel like your heart is “doing something funny”, but it tends to resolve itself so you don’t think much of it. If asked, you have noticed that your ankles get quite puffy, this tends to be worse in the evenings.

ICE: Only volunteer this is directly asked. You are actually quite worried that you’re taking a turn for the worse. You’ve been feeling tired all the time and can’t do what you used to. Your husband Bert died after a long battle with COPD and it’s “no way to go”, so you are scared that you’ve now developed it yourself. You want reassurance and inhalers from the doctor.

High blood pressure Knee replacement 5 years ago (due to wear and tear) If asked, you think you did have rheumatic fever as a child.

DH: Diltiazem (you can’t remember the dose) paracetamol and ibuprofen for wear-and-tear

SH: You live with your four cats (names above) whom are your life and soul. Fang only has one ear after he got into a fight with a horrible tabby that lives at number 42, but he likes nothing more than a good cuddle. There’s one flight of stairs at home and you only have an upstairs bathroom because you’re not posh like the doctor! It is sometimes difficult to get there in time because you have to stop for a rest at the top of the stairs, but otherwise you manage fine. You have no children, but your neighbour quite often pops over for a cuppa over Corrie (Coronation street). She takes you shopping because you can’t drive and getting about is becoming difficult. You used to be a baker in a cake shop. You retired on your 60th birthday and had quite the send off! You used to smoke when you were a girl but haven’t since your 30s. You smoked about 10/day from your mid-teens. You do like a glass of wine on an evening, a bottle of red will last you about 4 days.

Please observe the student taking the history and performing the examination.

They should perform a cardiovascular examination, however, a respiratory examination would also be appropriate Ask them to summarise their findings succinctly, and then present their differentials. Topics for discussion: - How would you initially investigate Mrs Pamil - What risk factors for heart failure does she have - How would manage an acute exacerbation of heart failure - How would manage heart failure long term - What are some common causes of heart failure - How likely is COPD in this patient - How would you distinguish between COPD and HF in this lady?