Respiratory
History OSCE Guide
Respiratory history stations are common in OSCEs. The patient may present with cough, shortness of breath, wheeze, chest pain, sputum production or coughing up blood.
You want to explore the presenting symptom properly, ask about important associated symptoms, screen for red flags, and take a social history that actually helps you work out what might be going on.
Respiratory histories are a good example of why social history matters. Smoking, vaping, occupation, travel, living conditions, TB contacts, pets and birds can all point you towards diagnoses that are easy to miss if you rush.
How to take a Focused Respiratory History in an OSCE
Explore the Presenting Complaint using OPERA
For respiratory symptoms like cough, breathlessness or wheeze, OPERA is a useful framework.
Use it to understand when the symptom started, how it has changed, what makes it better or worse, and what associated symptoms help you build the differential.
ONSET
Ask when the symptom started and whether it came on suddenly or gradually.
For example:
“When did this start?”
“Did it come on suddenly or gradually?”
“How long has it been going on?”
A cough that started yesterday is very different from a cough that has been present for eight weeks. Sudden breathlessness should make you think about acute causes such as PE, pneumothorax, asthma attack, pneumonia or acute heart failure.
EXACERBATING & RELIEVING FACTORS
Ask what brings the symptom on and what helps.
Think about exercise, cold air, dust, pets, pollen, work, indoor or outdoor environments, night-time symptoms, lying flat, rest, sitting up and inhaler use.
This can help point towards asthma, COPD, reflux, infection, occupational asthma, heart failure or environmental triggers.
PROGRESSION
Ask how the symptom has changed over time.
“Has it been getting better, worse or staying the same?”
“Has it ever gone away fully?”
“Have you had anything like this before?”
“Have you tried any treatment, and did it help?”
A symptom that is worsening, recurring, or not settling despite treatment should make you think more carefully.
RELEVANT ASSOCIATED SYMPTOMS
Ask about associated symptoms that help you build the differential.
Important symptoms include sputum, haemoptysis, breathlessness, wheeze, chest pain, fever, night sweats, weight loss, fatigue, hoarseness, recurrent infections and lumps or bumps, especially around the neck.
Try not to ask these as a random list. Link them to the presentation.
For example:
“Because this cough has been going on for a while, I’d like to ask a few questions about your general health. Have you noticed any weight loss, night sweats, fevers or feeling more tired than usual?”
Key Respiratory Symptoms to Ask
Cough
If the patient presents with cough, clarify the pattern.
Ask whether it is dry or productive, whether it is constant or intermittent, whether it is worse at night, whether it is triggered by exercise, cold air, dust or certain environments, and whether any treatment has helped.
A dry cough may fit with asthma, viral illness, reflux, ACE inhibitor use or interstitial lung disease.
A productive cough may suggest infection, COPD or bronchiectasis, depending on the history.
The important thing is not just whether they have a cough, but the pattern of the cough.
Shortness of Breath
Shortness of breath is one of the most important respiratory symptoms to explore.
Ask when it started, whether it came on suddenly or gradually, whether it is getting worse, whether it happens at rest or only on exertion, and what helps.
Quantify it properly.
For example:
“How far can you walk before you have to stop?”
“Can you manage stairs?”
“Is it worse lying flat?”
“I get breathless walking to the shops” tells you much more than “Yes, I get breathless.”
Chest Pain
Ask about chest pain.
If present, explore it properly.
Respiratory chest pain is often pleuritic, meaning it is worse on breathing in. This can occur with pneumonia, pleurisy or pulmonary embolism.
Ask where the pain is, what it feels like, whether it is worse on deep breathing, whether it moves anywhere, and whether it is associated with breathlessness, cough or haemoptysis.
If the pain sounds cardiac, switch into a chest pain history and screen for acute coronary syndrome.
respiratory red flags
Important red flags in a respiratory history include:
Coughing up blood
Persistent cough, especially if lasting several weeks
Unintentional weight loss
Night sweats
Persistent fever
Recurrent chest infections
Chest pain
Shortness of breath at rest
Hoarseness
New neck lumps or lymph nodes
Significant smoking history
Significant occupational exposure
TB contacts or high-risk living conditions
The red flags do not automatically mean cancer or TB. They mean the patient needs to be taken seriously and may need further investigation.
Sputum and Haemoptysis
If the patient is bringing anything up, clarify the sputum.
Ask about the amount, colour, frequency, whether it has changed, and whether there is any blood.
In an OSCE, ask about haemoptysis directly.
For example:
“Have you coughed up any blood at all?”
If they have, clarify how much blood there was, how often it has happened, whether it was mixed with sputum or frank blood, and whether it was associated with chest pain, breathlessness, fever, night sweats or weight loss.
Haemoptysis matters because it may be associated with lung cancer, tuberculosis, pulmonary embolism, bronchiectasis or infection.
Wheeze
Ask whether they have noticed wheeze or a whistling sound when breathing.
If yes, clarify the pattern.
Ask whether it is worse at night or early morning, triggered by exercise, cold air, dust, pets or pollen, and whether it improves with inhalers.
Also ask about previous asthma or COPD, and whether they have eczema, hay fever or allergies.
Wheeze may suggest asthma or COPD, but the timing, triggers and response to inhalers are what make the history useful.
Systemic Symptoms
Systemic symptoms can point towards infection, inflammatory disease, TB or malignancy.
Ask about fever, rigors, night sweats, weight loss, reduced appetite, fatigue, general decline, lumps or bumps, and rashes if relevant.
A useful way to ask is:
“Because this cough has been going on for a while, I’d like to ask a few questions about your general health. Have you noticed any weight loss, night sweats, fevers or feeling more tired than usual?”
Past Medical and Surgical History
Ask generally:
“Do you have any medical conditions?”
“Have you ever had any problems with your lungs or breathing before?”
“Have you ever been admitted to hospital with your breathing?”
Then ask a few focused questions depending on the presentation.
For example:
“Have you ever been diagnosed with asthma or COPD?”
“Have you ever had pneumonia or TB?”
“Have you ever had a blood clot in the lungs or legs?”
“Have you ever had any surgery or procedures on your chest or lungs?”
If they mention a known respiratory condition, explore it briefly:
“When were you diagnosed?”
“Are you under any specialists?”
“Have you ever needed hospital admission, oxygen, a nebuliser, or intensive care?”
Drug History and Allergies
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Ask about regular medications, over-the-counter medication and allergies.
Specifically check for inhalers:
“What inhalers do you use?”
“How often do you use them?”
“Are they helping?”
“Do you use a spacer?”
“Has anyone checked your inhaler technique recently?”
Also look out for:
- ACE inhibitors causing dry cough
- NSAIDs or beta-blockers worsening bronchospasm
- Anticoagulants if coughing up blood