You take a detailed history from Mr Smith.

His breathlessness has been getting worse over the preceding year and his exercise tolerance shorter. He has a nocturnal cough, orthopnoea and paroxysmal nocturnal dypsnoea, but no cough during the day. He does not expectorate any sputum and has no haemoptysis or wheeze. He does not have fevers or rigors and has no unwell contacts.

He does not take anything apart from Ramipril, including over the counter or illicit drugs.

On direct questioning, he describes some chest tightness at peak exertion, but he attributes this to being breathless. He is a lifelong non-smoker and worked as an accountant.

Review of systems is unremarkable; in particular, he has no symptoms suggestive of bleeding.