Lesson 1Past cardiac history, prior heart failure, coronary disease, revascularization, arrhythmias, and hospitalizationsThis section reviews how to obtain a precise past cardiac history, including prior heart failure, coronary disease, revascularization, arrhythmias, and hospitalizations, to refine differential diagnosis, prognosis, and therapeutic options.
Documented heart failure diagnosisCoronary disease and prior MI detailsPCI, CABG, and other revascularizationHistory of atrial or ventricular arrhythmiasPrior cardiac and HF hospitalizationsBaseline LVEF and prior imagingLesson 2Associated symptoms: chest pain, palpitations, syncope, presyncope, fever, cough productive vs dryThis section details how to systematically explore chest pain, palpitations, syncope, presyncope, and respiratory or infectious symptoms, helping distinguish cardiac from noncardiac causes and identify red flags requiring urgent escalation.
Character and timing of chest painPalpitations pattern and triggersSyncope and presyncope red flagsFever, chills, and infection cluesCough type, sputum, and hemoptysisPleuritic versus pressure-like painLesson 3Onset, duration, and progression of breathlessness and recent precipitating eventsHere we structure questions on onset, duration, and progression of breathlessness, along with recent precipitating events, to distinguish acute, subacute, and chronic patterns and identify triggers such as infection, ischemia, or nonadherence.
Exact onset and time course of dyspneaStable, improving, or worsening patternTriggers: exertion, rest, or recumbencyRecent infections, fevers, or travelDietary or medication nonadherenceRecent surgery, trauma, or pregnancyLesson 4Exercise tolerance, daily activity changes, and weight gain patternWe explore how to evaluate exercise tolerance, daily activity changes, and weight gain patterns, using functional history and recent trends to gauge congestion, response to therapy, and need for adjustment of diuretics or other treatments.
Baseline versus current activity levelDyspnea with stairs or short walksRecent reduction in daily activitiesDaily weight monitoring practicesRapid weight gain and fluid retentionImpact on work and caregiving rolesLesson 5Social and functional status, support at home, ability to attend follow-up, and access to transport/emergency servicesThis section guides assessment of social and functional status, home support, follow-up capacity, and access to transport or emergency services, informing safe discharge planning, self-management, and need for additional community resources.
Living situation and caregiver supportAbility to perform basic daily tasksHealth literacy and self-management skillsReliability of transport to follow-upAccess to pharmacy and emergency careFinancial or insurance constraintsLesson 6Fluid intake, salt intake, alcohol use, and recent medication changes or missed dosesHere we focus on assessing fluid and salt intake, alcohol use, and recent medication changes or missed doses, clarifying common precipitants of acute decompensated heart failure and guiding targeted patient education and counseling.
Daily fluid volume and restrictionsDietary sodium sources and habitsAlcohol quantity, pattern, and bingesRecent new or stopped medicationsMissed doses of heart failure drugsPatient understanding of regimenLesson 7Medication adherence, over-the-counter drugs, complementary medicines, and recent NSAID or steroid useThis section addresses medication adherence, over-the-counter drugs, complementary therapies, and recent NSAID or steroid use, highlighting agents that worsen fluid retention, blood pressure, or renal function in heart failure patients.
Barriers to taking prescribed medicinesUse of OTC cold and pain remediesRecent NSAID or COX-2 inhibitor useSystemic or inhaled steroid exposureHerbal and complementary productsPharmacy reconciliation and recordsLesson 8Comorbidities and risk factors: hypertension control, diabetes control, chronic lung disease, renal disease, and sleep apneaThis section covers eliciting comorbidities and risk factors, including hypertension, diabetes, chronic lung disease, renal disease, and sleep apnea, emphasizing control status and interactions that influence acute dyspnea and heart failure severity.
Hypertension history and control levelDiabetes duration and complicationsCOPD, asthma, and lung function historyChronic kidney disease stage and trendsScreening for sleep apnea symptomsObesity, smoking, and lipid profileLesson 9Orthopnea, paroxysmal nocturnal dyspnea, and nocturnal cough detailsWe examine targeted questioning about orthopnea, paroxysmal nocturnal dyspnea, and nocturnal cough, including onset, frequency, and positional triggers, to differentiate heart failure from pulmonary or upper airway causes of nighttime symptoms.
Number of pillows and sleep positionTiming and frequency of PND episodesNocturnal cough pattern and triggersRelief with sitting or standing upOverlap with reflux or asthma symptomsImpact on sleep quality and fatigueLesson 10Symptoms suggesting alternative diagnoses: unilateral leg pain/swelling, hemoptysis, fever, pleuritic chest pain, or neurologic signsWe focus on symptoms suggesting alternative diagnoses, such as pulmonary embolism, pneumonia, pneumothorax, or neurologic events, teaching targeted questions that help differentiate these from primary heart failure presentations.
Unilateral leg pain or swelling historyPleuritic chest pain and PE suspicionFocal neurologic deficits or confusionHigh fever, rigors, and pneumonia cluesSudden onset dyspnea and pneumothoraxRed flags requiring urgent escalation
