Asthma
History OSCE Guide
Asthma is a common respiratory condition that can cause episodes of wheeze, cough, chest tightness and shortness of breath.
What this station is testing
In an asthma history station, the examiner wants to see that you can:
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Recognise an asthma pattern, including variable wheeze, cough, chest tightness or breathlessness
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Assess control, including night waking, reliever use and activity limitation
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Ask about triggers, atopy and environmental exposures
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Check inhaler use, adherence, spacer use and technique
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Identify previous severe attacks, including ED attendance, admission, ICU or ventilation
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Recognise red flags suggesting acute severe or life-threatening asthma
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Summarise the case clearly
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?”
“Have you had symptoms like this before?”
PROGRESSION
“Has it been getting better, worse or staying the same?”
“Are symptoms happening more often than usual?”
“Are you needing your reliever inhaler more?”
“Are you waking at night with symptoms?”
EXACERBATING & RELIEVING FACTORS
“What tends to trigger your symptoms?”
“Are symptoms worse at night or early morning?”
“Does exercise, cold air, dust, pets, pollen, smoke, vaping, damp housing or work make it worse?”
“Does your reliever inhaler help?”
ASSOCIATED SYMPTOMS
Ask about:
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Cough
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Wheeze
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Chest tightness
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Shortness of breath
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Sputum
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Fever
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Chest pain
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Haemoptysis
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Weight loss
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Night sweats
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Recurrent infections
Fever, haemoptysis, weight loss, night sweats or recurrent infections should make you think about alternative or additional diagnoses.
Explore the Presenting Complaint using OPERA
Assess Asthma Control
Ask how often symptoms happen and how much asthma affects life.
Useful questions include:
“How often do you get symptoms during the day?”
“Do you wake at night with coughing, wheeze or breathlessness?”
“How often are you using your reliever inhaler?”
“Has your reliever use increased recently?”
“Is asthma limiting exercise, work, school or daily activities?”
Poor control is suggested by frequent symptoms, night waking, increased reliever use, activity limitation or recent exacerbations.
Inhaler History
Inhaler history is one of the most important parts of an asthma history.
Ask:
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“What inhalers do you use?”
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“Which one do you take every day?”
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“Which one do you use when symptoms flare up?”
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“How often are you using your reliever?”
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“Do you ever miss doses?”
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“Do you use a spacer?”
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“Has anyone checked your inhaler technique recently?”
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“Do the inhalers help?”
Do not just ask whether they are on inhalers. Clarify what they use, how often they use it, whether they take it correctly and whether it works.
Previous Asthma Severity
Ask about previous severe attacks.
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“Have you ever needed to go to ED because of your asthma?”
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“Have you ever been admitted to hospital?”
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“Have you ever needed nebulisers or oral steroids?”
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“Have you ever been admitted to ICU or needed help with your breathing?”
Previous severe attacks, especially ICU admission or ventilation, increase future risk.
Past Medical History
Ask about asthma history and other conditions that may affect breathing.
Useful questions include:
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“When were you diagnosed with asthma?”
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“Have you ever had eczema, hay fever or allergies?”
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“Have you had frequent chest infections or any other lung conditions?”
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“Do you have any heart problems?”
Relevant background conditions include eczema, hay fever, allergic rhinitis, reflux, recurrent chest infections, COPD, bronchiectasis or cardiac disease.
Atopy supports asthma, but alternative diagnoses should be considered if the history does not fit.
Drug History
Ask about current asthma treatment and medications that could affect symptoms.
Useful questions include:
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“What inhalers or tablets do you take for asthma?”
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“Do you take your preventer every day?”
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“Have you needed steroid tablets recently?”
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“Do you take aspirin, ibuprofen or beta-blockers?”
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“Do you have any medication allergies?”
Important points include reliever use, preventer adherence, spacer use, recent steroid courses, NSAIDs, beta-blockers and allergies.
Family History
Ask about asthma and atopy in the family.
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“Does asthma run in your family?”
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“Does anyone in the family have eczema, hay fever or allergies?”
A family history of asthma or atopy can support the diagnosis.
Social History
Social history is important because asthma can be affected by environment and exposures.
Useful questions include:
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“Do you smoke or vape?”
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“Is there any damp, mould or smoke exposure at home?”
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“Do your symptoms get worse at work, school or around animals?”
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“Is asthma affecting exercise, work, school, sleep or social life?”
Important areas include smoking, vaping, passive smoke exposure, pets, damp housing, occupational dust or fumes, exercise, school or work absence, and impact on daily life.
Ideas, Concerns and Expectations
Ask naturally:
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“What do you think might be causing this flare-up?”
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“Is there anything in particular you’re worried about?”
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“What were you hoping we could do today?”
Breathlessness can be frightening, especially if the reliever inhaler is not helping as much as usual.
Red flags in an asthma history
Important red flags include:
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Breathlessness at rest
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Difficulty speaking in full sentences
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Reliever inhaler not helping
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Rapidly worsening symptoms
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Exhaustion or drowsiness
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Cyanosis
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Silent chest
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Previous ICU admission
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Previous ventilation
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Chest pain
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Haemoptysis
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Fever or suspected infection
These features should make you think about acute severe or life-threatening asthma and prompt urgent assessment.
How COPD History Differs from Asthma
COPD can overlap with asthma, but the emphasis is different.
COPD is usually more associated with older age, smoking history, chronic productive cough, progressive breathlessness, recurrent infective exacerbations, previous admissions, home oxygen or nebuliser use, pulmonary rehabilitation and frailty.
Asthma is usually more variable, often triggered by specific exposures, commonly worse at night or early morning, and often associated with atopy.
Diagnosis and Investigations
Asthma is diagnosed using the symptom pattern, examination findings and objective tests.
Useful tests may include peak flow monitoring, spirometry with reversibility, FeNO testing, blood eosinophils and chest X-ray if another diagnosis is being considered.
In a history station, the key point is that asthma is not diagnosed from one question alone. It is based on a typical pattern of symptoms, supported by objective evidence where needed.
Example Summary:
“Peter is a 25-year-old man with asthma since childhood, presenting with three days of worsening wheeze and shortness of breath. His symptoms are worse at night and on exertion, and he can now only walk around 100 metres before stopping. He has used his blue reliever inhaler six times today with only partial relief. He takes a regular preventer inhaler but sometimes forgets it. He had one hospital admission as a child, but no ICU admission. He also has eczema, hay fever and a family history of asthma. Overall, I would be concerned about an asthma exacerbation with poor control.”
Examiner Questions
Q1: What features suggest asthma?
Variable wheeze, cough, chest tightness or shortness of breath, often worse at night or early morning, triggered by exercise, cold air, allergens or viral infection, and improved by inhalers.
Atopy or family history can support the diagnosis.
Q2: What suggests poor asthma control?
Night-time waking, frequent symptoms, increased reliever use, reduced exercise tolerance, and a family history of asthma. Overall, I would be concerned about an asthma exacerbation with poor control.”
Q3: What would you ask about inhalers?
Ask which inhalers they use, how often they use their reliever, whether use has increased, whether they take their preventer regularly, whether they use a spacer, and whether technique has been checked.
Q4: What previous asthma history matters?
Ask about previous ED attendances, hospital admissions, nebulisers, oral steroids, ICU admission or ventilation.
Previous severe attacks increase future risk.
Q5: What triggers should you ask about?
Exercise, cold air, dust, pets, pollen, viral infections, smoke, vaping, strong smells, stress, damp housing and workplace exposures.
Q6: What would you do next?
Assess clinically with observations, oxygen saturations and respiratory examination.
Be concerned if the patient is very breathless, hypoxic, unable to speak in full sentences, exhausted, deteriorating or has a silent chest.
Also review inhaler technique, adherence and triggers.
Q7: What advice is important before discharge?
Check inhaler technique, encourage preventer adherence, advise using a spacer if appropriate, provide a personalised asthma action plan and safety-net if symptoms worsen.
Quick Asthma History Structure
A focused asthma history can be structured around:
Explore symptoms using OPERA
Ask about night-time or early morning symptoms
Ask about triggers
Assess control, including reliever use and activity limitation
Ask about inhalers, adherence, spacer use and technique
Ask about previous severe attacks
Ask about atopy, smoking, vaping and occupation
Screen for red flags
Explore ICE
Summarise and suggest examination if asked
Key Message:
A strong asthma history is about pattern, control and risk.
Work out whether the story fits asthma, how well controlled it is, whether inhalers are being used properly, and whether the patient is currently unsafe.
The highest-yield areas are triggers, night-time symptoms, reliever use, preventer adherence, inhaler technique, previous severe attacks, atopy, smoking, occupation and impact on daily life.