OSCE Respiratory - History Taking

Related Subjects: | Assessing Breathlessness

🫁 Respiratory symptoms are common in OSCEs and often overlap with cardiac, infective, and even metabolic causes. 💡 A strong history is built around timeline, triggers, associated symptoms, risk factors, and functional impact. Always ask yourself: Is this airway disease, parenchymal lung disease, pleural disease, pulmonary vascular disease, cardiac failure, or something systemic?

🩺 Core Symptoms for OSCE

• 🫁 Breathlessness and reduced exercise tolerance
• 💥 Chest pain, orthopnoea, paroxysmal nocturnal dyspnoea (PND)
• 😮‍💨 Cough, wheeze, sputum production
• 🩸 Haemoptysis, fever, weight loss, night sweats
• 🚬 Smoking, vaping, and drug history
• 🌾 Exposure history: asbestos, dust, birds, animals, occupational inhalants
• 🏠 Functional impact: effect on work, exercise, sleep, social activities, and activities of daily living (ADLs)

📖 Introduction

• 🫀🫁 Respiratory and cardiac symptoms often overlap, so many patients present with a mixture of both.
• 🧭 Build a clear timeline: when did the symptom start, how quickly did it come on, and is it progressing?
• 📏 Always quantify symptoms where possible:
  • Walking distance
  • Number of stairs
  • Sputum volume
  • Amount of haemoptysis
  • Weight loss
  • Pack-years smoked
• 🔍 Clarify vague phrases like “for a while” or “off and on” by converting them into days, weeks, months, or years.
• 🏡 Ask about occupational exposure, smoking, pets, birds, mould, and recent travel.
• 🧑‍🦽 Assess function carefully: can they wash, dress, climb stairs, shop, cook, and manage independently?

🫁 Breathlessness

• ⏱️ Onset: sudden or gradual? When did it start?
• 📈 Progression: is it getting worse, stable, or fluctuating?
• 🏃 Trigger: exertion, rest, cold air, allergens, infection, lying flat, or sleep?
• 🌙 Nocturnal symptoms: orthopnoea or PND suggest cardiac failure, but nocturnal wheeze may suggest asthma.
• 🧯 Relieving factors: inhalers, sitting upright, rest, fresh air?
• 📍 Pattern: episodic or persistent? Does it correlate with work, home, or holidays?
• 🚬 Smoking, vaping, or recreational drug use
• 💊 Medication history: e.g. amiodarone, beta-blockers, ACE inhibitors, chemotherapy
• 🐦 Exposure history: pets, birds, mould, dust, chemicals, asbestos
• 🩺 Quantify exercise tolerance: “How far can you walk now compared with 3 or 6 months ago?”

⏳ Timing of Breathlessness

• ⚡ Rapid onset within minutes
  • 🫁 Asthma
  • 🫀 Acute left ventricular failure / pulmonary oedema
  • 🩸 Pulmonary embolism
  • 🚫 Airway obstruction / foreign body
  • 🌰 Anaphylaxis or laryngeal oedema
  • 💨 Pneumothorax
  • 😰 Panic attack / hyperventilation
• 🕐 Rapid onset over hours
  • 🫁 Acute asthma or COPD exacerbation
  • 🫀 Pulmonary oedema
  • 🦠 Pneumonia
  • 🧫 ARDS
  • 🩸 Pulmonary embolism
  • 💧 Pleural effusion
  • ⚗️ Metabolic acidosis such as DKA
• 📅 Gradual onset over weeks
  • 💔 Congestive cardiac failure
  • 🫁 Interstitial lung disease
  • 🪨 Progressive massive fibrosis
  • 🦠 Subacute infection or malignancy
• 📆 Gradual onset over months to years
  • 🚬 COPD
  • 🫁 Idiopathic pulmonary fibrosis
  • 🌿 Sarcoidosis
  • 🦠 Bronchiectasis
  • 🧬 Cystic fibrosis
  • 🫀 Chronic heart failure
  • 🧠 Neuromuscular weakness / hypoventilation
• 🔁 Episodic breathlessness
  • 🫁 Asthma
  • 🫀 LVF
  • ❤️ Anginal equivalent
  • 🩸 PE
  • 🌾 Hypersensitivity pneumonitis
  • 😰 Panic attacks

😮‍💨 Cough

• 📅 Onset: when did it begin?
• 🔁 Pattern: acute, subacute, chronic, intermittent?
• 🌙 Timing: worse at night, early morning, after meals, or lying down?
• 🍽️ Triggers: eating, drinking, exercise, cold air, allergens, reflux?
• 📈 Trend: improving, worsening, or unchanged?
• 🩸 Associated red flags: haemoptysis, weight loss, fever, night sweats, hoarseness
• 🧪 Sputum: quantity, colour, thickness, smell, blood
• 🚬 Smoking / occupational exposure
• 💊 Medication review: especially ACE inhibitors

🤧 Causes of Cough

• 🦠 Tracheitis, bronchitis, pneumonia
• 🫁 Asthma, COPD
• 💧 Pulmonary oedema
• 🌙 Post-nasal drip / upper airway cough syndrome
• 🔥 Gastro-oesophageal reflux
• 🧱 Bronchiectasis
• 🎗️ Lung cancer
• 💊 ACE inhibitor-induced cough

🔎 Nocturnal Cough

• 🫁 Asthma
• 🌙 Post-nasal drip
• 🔥 Reflux
• 🫀 Pulmonary oedema / heart failure

🩸 Haemoptysis

• 🦠 Infection: pneumonia, bronchitis, TB
• 🩸 Pulmonary embolism
• 🎗️ Lung cancer, especially in older smokers
• 💧 Pulmonary oedema
• 🫁 Bronchiectasis

🧪 Sputum

• 🟢 Purulent (green/yellow): often bacterial infection
• 🩸 Blood-stained: PE, malignancy, infection
• 🟤 Rusty: classically pneumococcal pneumonia
• 🫧 Copious / foul-smelling: bronchiectasis, abscess
• 🧴 Thick / tenacious: cystic fibrosis, severe bronchiectasis

🌡️ Fever

• 🦠 Pneumonia or tuberculosis
• 🎗️ Lymphoma or malignancy
• 🦴 Connective tissue disease
• 🌾 Extrinsic allergic alveolitis / hypersensitivity pneumonitis

⚖️ Unexpected Weight Loss

• 🎗️ Malignancy
• 🦠 Tuberculosis
• 🫁 Idiopathic pulmonary fibrosis
• 🚬 Advanced COPD

🎵 Other Symptoms to Explore

• 🎺 Stridor — suggests upper airway obstruction
  • 🚨 Epiglottitis
  • 🌰 Anaphylaxis / laryngeal oedema
  • 🚫 Foreign body
  • 🎗️ Laryngeal tumour
  • 🧒 Croup
• 🎶 Wheeze — usually suggests lower airway narrowing
  • 🫁 Asthma
  • 🚬 COPD
  • 🫀 Pulmonary oedema (“cardiac wheeze”)

🚬 Smoking History

• Heavy smoking increases the likelihood of COPD, lung cancer, and cardiovascular disease.
• 📏 Calculate pack-years = packs per day × years smoked.
• 🔍 Look for associated clues such as clubbing, cachexia, recurrent infections, or suspicious CXR changes.

🏭 Occupational History and Animal Exposure

• 🧱 Ask about asbestos, silica, coal dust, spray paints, welding fumes, flour, cotton, and chemical inhalants.
• 🐦 Ask about birds, poultry, pets, farm animals, and mould exposure.
• 🏠 Check whether symptoms improve away from work or worsen in specific environments.
• 🚬 Consider second-hand smoke exposure as well.

💥 Chest Pain

• 🩸 Pulmonary embolism or pulmonary infarction — often pleuritic
• 🦠 Pneumonia with pleurisy
• 💨 Pneumothorax
• 🎗️ Tumours such as mesothelioma or rib metastases
• 🦴 Rib fracture or musculoskeletal pain
• ❤️ Acute coronary syndrome
• 🔥 Oesophagitis
• 💓 Pericarditis

🌍 Miscellaneous Considerations

• 💉 Sexual / IV drug history — possible HIV-related infections such as PCP
• 🏨 Recent travel or hotel stay — think Legionella
• ✈️ Travel to endemic areas — TB, fungal infections, unusual pathogens
• 🧪 Consider rare exposures where relevant, including anthrax or occupational toxins

🔎 Investigations

• 🩸 Blood tests: FBC, CRP, U&E, LFTs, D-dimer where appropriate
• 🩻 Imaging: CXR, CT, HRCT if indicated
• 📉 Lung function: serial PEFR, spirometry
• 🔬 Microbiology: sputum culture, TB testing if indicated
• 🫁 Special tests: bronchoscopy, echocardiography, ENT review depending on the history

🌟 OSCE pearl: A good respiratory history is not just a list of symptoms — it is a timeline + severity + triggers + exposures + function story. 💡 Always ask: How breathless? Since when? What brings it on? What else came with it? What can they no longer do?