Respiratory
History OSCE Guide
Respiratory history stations are common in OSCEs. Patients may present with cough, shortness of breath, wheeze, chest pain, sputum production or coughing up blood.
In a respiratory history station, the examiner wants to see that you can:
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Identify the main respiratory symptom
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Build a pattern from cough, sputum, haemoptysis, breathlessness, wheeze and chest pain
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Screen for red flags such as haemoptysis, weight loss, night sweats or severe breathlessness
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Consider key causes, including asthma, COPD, infection, PE, TB and malignancy
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Ask about respiratory risk factors such as smoking, occupation, travel, TB contacts and environmental exposures
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Recognise when urgent assessment or further investigation is needed
What this station is testing
Explore the Presenting Complaint using OPERA
Start open:
“Can you tell me what has brought you in today?”
Then explore the main symptom.
ONSET
“When did this start?”
“Did it come on suddenly or gradually?”
“How long has it been going on?”
Sudden breathlessness should make you think about PE, pneumothorax, asthma attack, pneumonia or acute heart failure.
PROGRESSION
“Has it been getting better, worse or staying the same?”
“Has this happened before?”
“Have you tried anything for it?”
Worsening, recurrent or persistent symptoms need careful assessment.
EXACERBATING & RELIEVING FACTORS
“What brings it on?”
“What makes it better?”
“Is it worse with exercise, cold air, dust, pets, work, at night or lying flat?”
“Do inhalers, rest or sitting upright help?”
These questions help identify triggers and separate respiratory from cardiac patterns.
ASSOCIATED SYMPTOMS
Ask about sputum, haemoptysis, breathlessness, wheeze, chest pain, fever, night sweats, weight loss, fatigue, hoarseness, recurrent infections and neck lumps.
Useful phrasing:
“Have you brought up any sputum or blood?”
“Any wheeze, chest pain or shortness of breath?”
“Any fevers, night sweats, weight loss or feeling more tired than usual?”
Key Respiratory Symptoms to Ask
Cough
If the patient has a cough, clarify whether it is dry or productive, constant or intermittent, worse at night, triggered by exercise, cold air, dust or work, and whether 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.
Sputum and Haemoptysis
If they are bringing up sputum, ask about amount, colour, frequency and whether it has changed.
Always ask directly:
“Have you coughed up any blood at all?”
If yes, clarify the amount, frequency, whether it was mixed with sputum or frank blood, and whether there was chest pain, breathlessness, fever, night sweats or weight loss.
Haemoptysis can be associated with lung cancer, TB, PE, bronchiectasis or infection.
Shortness of Breath
Ask whether the breathlessness came on suddenly or gradually, whether it is worsening, whether it occurs at rest or on exertion, and what helps.
Quantify it:
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“How far can you walk before you have to stop?”
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“Can you manage stairs?”
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“Is it worse lying flat?”
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“I get breathless walking to the shops” tells you more than “yes, I get breathless.”
Wheeze
Ask whether they have noticed wheeze or a whistling sound.
If yes, 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 asthma, COPD, eczema, hay fever and allergies.
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 PE.
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.
Systemic Symptoms
Systemic symptoms can point towards infection, TB, inflammatory disease or malignancy.
Ask about fever, rigors, night sweats, weight loss, reduced appetite, fatigue, general decline, rashes and lumps.
Useful phrasing:
“Because this has been going on for a while, have you noticed any weight loss, night sweats, fevers or feeling more tired than usual?”
respiratory red flags
Important red flags include:
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Coughing up blood
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Persistent cough, especially lasting several weeks
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Unintentional weight loss
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Night sweats
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Persistent fever
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Recurrent chest infections
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Chest pain
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Shortness of breath at rest
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Hoarseness
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New neck lumps or lymph nodes
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Significant smoking history
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Significant occupational exposure
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TB contacts or high-risk living conditions
These red flags do not automatically mean cancer or TB. They mean the symptoms need to be taken seriously and may need further investigation.
Past Medical and Surgical History
Past medical history can give important clues.
Relevant conditions to look out for include asthma, COPD, pneumonia, TB, previous PE or DVT, bronchiectasis, interstitial lung disease, lung cancer, heart failure, ischaemic heart disease, immunosuppression and previous chest surgery.
If they have a known respiratory condition, ask briefly about severity:
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“When were you diagnosed?”
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“Are you under any specialists?”
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“Have you ever needed hospital admission, oxygen, nebulisers or intensive care?”
Drug History and Allergies
Ask about regular medications, over-the-counter medication and allergies.
Specifically check for inhalers:
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“What inhalers do you use?”
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“How often do you use them?”
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“Are they helping?”
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“Do you use a spacer?”
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“Has anyone checked your inhaler technique recently?”
Also look out for:
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ACE inhibitors causing dry cough
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NSAIDs or beta-blockers worsening bronchospasm
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Anticoagulants if coughing up blood
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COCP, HRT or other clot-risk medication if considering PE
Ask about family history of lung disease, asthma, COPD, lung cancer or TB.
If a relative died from lung cancer or another serious condition, ask sensitively.
Family History
Social history is one of the most important parts of a respiratory history.
Ask about smoking and vaping:
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“Do you smoke at all?”
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“How many cigarettes would you smoke per day?”
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“How many years have you smoked for?”
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“Do you vape or use e-cigarettes?”
Ask about occupation and exposures:
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“What do you do for work?”
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“Have you ever worked around dust, fumes, chemicals, asbestos or animals?”
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Ask about travel, contacts and living conditions:
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“Have you travelled anywhere recently?”
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“Has anyone around you been unwell?”
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“Have you ever been in contact with someone with TB?”
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“Could I ask what your living situation is like at home?”
Ask about pets, birds and hobbies:
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“Do you have any pets or birds at home?”
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“Any hobbies that involve dust, animals or chemicals?”
Also ask about baseline exercise tolerance, impact on work or daily activities, support at home, alcohol and recreational drug use where relevant.
Social History and Respiratory Risk Factors
Ideas, Concerns and Expectations.
Respiratory symptoms can make patients anxious, especially if there are red flags or a family history of lung cancer.
Example Summary:
“Peter is a 65-year-old man presenting with an eight-week history of persistent cough which has not improved despite antibiotics. The cough is productive of white-brown sputum and he has recently noticed haemoptysis. He also reports unintentional weight loss, fatigue and occasional night sweats. He is a current smoker with a significant smoking history and his mother died from lung cancer. Overall, I would be concerned about a serious underlying respiratory cause and would want to examine him and arrange further investigation.”
Ask:
“What do you think might be causing this?”
“Is there anything in particular you are worried this could be?”
“What were you hoping we could do today?”
If the patient mentions cancer, acknowledge the concern without falsely reassuring them:
“I can understand why that would be on your mind. It is too early to say exactly what is causing this, but I agree these symptoms need to be taken seriously. I’d like to examine your chest and arrange the appropriate tests.”
Respiratory Patterns to Recognise
Lung Cancer
Lung cancer becomes more concerning when cough is persistent or worsening and associated with haemoptysis, weight loss, reduced appetite, fatigue, chest pain, hoarseness, smoking history, family history or occupational exposure such as asbestos.
Bronchiectasis
Bronchiectasis may present with chronic productive cough, recurrent chest infections, large amounts of sputum, haemoptysis, breathlessness and fatigue.
Pneumonia or Infection
Infection becomes more likely when cough is associated with fever, sputum, pleuritic chest pain, shortness of breath and feeling acutely unwell.
Tuberculosis
Think about TB when cough is associated with haemoptysis, weight loss, night sweats, fever, fatigue, travel to areas with higher TB prevalence, close TB contact, crowded living conditions or immunosuppression.
Pulmonary Fibrosis
Pulmonary fibrosis may present with gradually worsening breathlessness, dry cough, reduced exercise tolerance and occupational or environmental exposure.
Pulmonary Embolism
Consider PE if there is sudden shortness of breath, pleuritic chest pain, haemoptysis, calf pain or unilateral leg swelling, recent surgery, immobility, long travel, previous DVT or PE, pregnancy, oestrogen use or active cancer.
Possible Examiner Questions & Model Answers
Q1: What are your top differential diagnoses?
“My differentials would depend on the presenting symptoms. For a persistent cough with haemoptysis, weight loss and smoking history, my main concern would be lung cancer. I would also consider TB, bronchiectasis, pneumonia, pulmonary embolism and pulmonary fibrosis depending on the wider history.”
Q2: What features make you concerned about lung cancer?
Persistent or worsening cough, haemoptysis, weight loss, reduced appetite, fatigue, chest pain, hoarseness, smoking history, family history of lung cancer and occupational exposure such as asbestos.
Q3: What investigations would you request?
I would examine the patient, including a respiratory examination and lymph node examination.
Depending on the presentation, I would consider observations including oxygen saturations, chest X-ray, bloods such as FBC, U&Es, LFTs and CRP, sputum sample if productive cough or TB is suspected, suspected cancer referral if criteria are met, CT chest if indicated, TB testing if clinically suspected, and spirometry if obstructive lung disease is suspected and safe.
Q4: Why is social history important in respiratory histories?
Social history can point towards the diagnosis.
Smoking increases the risk of lung cancer and COPD. Asbestos exposure can suggest mesothelioma. Birds can suggest hypersensitivity pneumonitis. Crowded living conditions or TB contacts can suggest tuberculosis. Occupational dust or fumes can suggest occupational lung disease.
Q5: How would you respond if the patient is worried about cancer?
“I can understand why you are worried, especially with your family history. It is too early to say exactly what is causing the symptoms, but I agree they need to be taken seriously. I would like to examine you and arrange the appropriate tests.”
A focused respiratory history can be structured around:
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Explore the main symptom using OPERA
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Ask about cough, sputum, haemoptysis, breathlessness, wheeze and chest pain
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Screen for systemic symptoms and red flags
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Ask about PMH, drugs, inhalers, allergies and family history
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Take a focused respiratory social history
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Explore ICE
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Summarise and suggest examination or investigations if asked
Quick Structure to Remember
Key Message
A strong respiratory history is not just about asking whether the patient has a cough or shortness of breath.
Explore the symptom, ask about sputum and haemoptysis, screen for systemic symptoms, and take a social history that helps you build the differential.
In respiratory medicine, the diagnosis often comes from the details: smoking, occupation, travel, living conditions, TB contacts, pets, birds, sputum, blood, weight loss and the patient’s own concerns.
A focused respiratory history can be structured around:
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Open the consultation and let the patient describe the problem
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Explore the main symptom using OPERA
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Ask about cough, sputum and haemoptysis
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Explore breathlessness, wheeze and chest pain where relevant
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Screen for systemic symptoms, including fever, weight loss and night sweats
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Screen for respiratory red flags
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Ask about relevant background history, including asthma, COPD, TB, PE or recurrent infections
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Cover medications, including inhalers, inhaler technique and drugs that may worsen symptoms
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Take a focused social history, including smoking, vaping, occupation, travel, TB contacts, living conditions, pets and birds
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Explore ideas, concerns and expectations
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Summarise and close