Shortness of Breath History (OSCE focused) 🫁
🧑⚕️ Candidate Instructions
You are the medical student on call in the Acute Medical Unit.
A 65-year-old patient has been admitted with shortness of breath.
Please take a focused but structured history to determine the most likely cause.
You do NOT need to examine the patient or discuss investigations or management at this stage.
🗂️ Structured History Framework
1️⃣ Presenting Complaint
- Onset - sudden or gradual?
- Duration - hours, days, weeks?
- Progression - stable, worsening, episodic?
- Trigger - exertion, lying flat, infection, allergen exposure?
2️⃣ Characterise the Breathlessness
- At rest or only on exertion?
- Orthopnoea (extra pillows?)
- Paroxysmal nocturnal dyspnoea (PND)
- Wheeze or chest tightness?
- Pleuritic pain?
- Stridor (upper airway obstruction)?
3️⃣ Associated Symptoms
- Cough (dry vs productive)
- Sputum colour and volume
- Haemoptysis ⚠
- Fever or rigors
- Chest pain (character and radiation)
- Ankle swelling
- Weight loss or night sweats
4️⃣ Risk Factors
- Smoking (pack-years)
- Recent surgery, travel, immobility (PE risk)
- Malignancy history
- Occupational exposures (asbestos, dust)
- Allergens, pets
5️⃣ Past Medical & Drug History
- Asthma / COPD
- Heart failure / IHD
- Previous PE or DVT
- Medication adherence (inhalers, diuretics, anticoagulants)
- Recent medication changes
6️⃣ Functional Impact (Examiner Favourite)
- Exercise tolerance - stairs? walking distance?
- Impact on activities of daily living
- Recent deterioration from baseline
7️⃣ ICE (Ideas, Concerns, Expectations)
- What do you think is causing it?
- Are you worried about anything in particular?
- What were you hoping we could do today?
🚨 Red Flags to Actively Elicit
- Acute collapse or syncope
- Severe chest pain
- Haemoptysis
- Stridor
- Inability to complete sentences
🔎 Expected Differential Diagnoses
- Respiratory: Asthma, COPD exacerbation, pneumonia, pulmonary embolism, pneumothorax, interstitial lung disease
- Cardiac: Heart failure, acute coronary syndrome, pulmonary oedema
- Other: Anaemia, metabolic acidosis, anxiety/panic attack
📝 Mark Scheme (10 Marks)
| Domain |
Marks |
What Examiners Want |
| Structure & Rapport |
2 |
Introduces self, open questions, clear structure, ICE explored |
| Characterisation |
2 |
Clarifies onset, severity, triggers, orthopnoea/PND |
| Associated Symptoms |
2 |
Cough, sputum, fever, chest pain, haemoptysis, ankle swelling |
| Risk Assessment |
2 |
Smoking, PE risks, cardiac history |
| Clinical Reasoning |
2 |
Offers sensible top 3 differentials and justifies briefly |
🧠 Teaching Commentary
The OSCE aim is not to list every cause - it is to demonstrate pattern recognition and safe clinical reasoning.
- Orthopnoea + PND + ankle swelling → Heart failure 🫀
- Sudden dyspnoea + pleuritic pain + risk factors → PE 🫁
- Wheeze + variability → Asthma 🌬️
- Chronic smoker + productive cough → COPD 🚬
- Fever + focal chest pain → Pneumonia 🦠
In UK OSCEs, candidates score highly when they:
- Assess functional limitation
- Actively exclude red flags
- Provide structured summary at the end
🧑⚕️ Case Examples - Acute Dyspnoea
-
Case 1 - Acute Severe Asthma: 🌬️
25-year-old unable to complete sentences, PEFR 30% predicted.
Teaching: Severity assessment is critical. Always ask about prior ICU admissions and steroid use.
-
Case 2 - Pulmonary Embolism: 🫁
Sudden dyspnoea after long-haul flight. Tachycardic, hypoxic.
Teaching: Sudden unexplained breathlessness + risk factors = PE until proven otherwise.
-
Case 3 - Acute LV Failure: ❤️🔥
Orthopnoea, pink frothy sputum, “bat’s wing” CXR.
Teaching: Orthopnoea strongly suggests cardiac origin.
-
Case 4 - Pneumonia: 🦠
Fever, productive cough, pleuritic pain.
Teaching: Always ask about systemic features.
-
Case 5 - Pneumothorax: ⚡
Sudden pleuritic pain in tall young man.
Teaching: Think pneumothorax in sudden onset pain + breathlessness.
-
Case 6 - Anaphylaxis: 🚨
Dyspnoea + rash + hypotension.
Teaching: Recognise airway compromise early.
