Anaemia
History OSCE Guide
How to take a Focused Anaemia History?
Anaemia is common in clinical practice and in OSCEs. The patient may present with tiredness, breathlessness on exertion, dizziness, palpitations, feeling faint or struggling with normal activities.
Anaemia is not really a diagnosis on its own. It is a sign that something else may be going on.
A good anaemia history should help you answer:
Does this sound like anaemia?
How severe are the symptoms?
Is there evidence of blood loss?
Could this be due to diet, malabsorption, chronic disease, medication, pregnancy or malignancy?
OSCE Talk Tip
Anaemia histories have two jobs:
Assess severity.
Look for the cause.
So after exploring tiredness, always ask about symptoms of low haemoglobin, blood loss, diet, malabsorption, chronic disease, medications and red flags.
The aim is not just to say “anaemia”. The aim is to work out why the patient may be anaemic.
“Can you tell me what has brought you in today?”
Then explore the symptom.
ONSET
“When did the tiredness start?”
“Did it come on suddenly or gradually?”
Anaemia often develops gradually over weeks or months. Sudden symptoms may suggest acute blood loss or another acute problem.
PROGRESSION
“Has it been getting better, worse or staying the same?”
“Is there anything you could do before that you can’t do now?”
This helps you assess severity and impact.
EXACERBATING & RELIEVING FACTORS
“What tends to make the tiredness worse?”
“Does rest or sleep help?”
“Are you still tired even after sleeping?”
Anaemia-related fatigue often does not fully improve with sleep.
ASSOCIATED SYMPTOMS
“Are you getting short of breath when walking or climbing stairs?”
“Have you noticed your heart racing or beating strongly?”
“Have you felt dizzy or light-headed?”
“Have you fainted or nearly fainted?”
“Any chest pain?”
“Are you managing your usual activities?”
Chest pain, syncope, breathlessness at rest or marked functional decline suggests more severe anaemia or another serious cause.
Explore the Presenting Complaint using OPERA
Look for Blood Loss
A key part of an anaemia history is asking about bleeding.
Ask:
“Have you noticed any bleeding from anywhere?”
Then check specifically for:
Vomiting blood
Black, sticky or tar-like stools
Fresh rectal bleeding
Blood in the urine
Coughing up blood
Nosebleeds
Easy bruising or unusual bleeding
If there is bleeding, clarify how much, how often and for how long.
Menstrual and Gynaecological History
In patients who have periods, ask sensitively about heavy bleeding.
Useful questions include:
“Would it be okay if I asked about your periods?”
“Are your periods heavy?”
“Do you pass clots?”
“Do you ever bleed through protection or need to change overnight?”
“Has this changed recently?”
“Do you get significant pain?”
In someone who is post-menopausal, ask:
“Have you had any vaginal bleeding since your periods stopped?”
Post-menopausal bleeding is a red flag.
Diet, Malabsorption and Systemic Symptoms
Ask about previous severe attacks.
“Have you ever needed to go to ED because of your asthma?”
“Have you ever been admitted to hospital?”
“Have you ever needed nebulisers or oral steroids?”
“Have you ever been admitted to ICU or needed help with your breathing?”
Previous severe attacks, especially ICU admission or ventilation, increase future risk.
Triggers, Atopy and Background
Ask about common triggers such as exercise, cold air, dust, pets, pollen, viral infections, smoke, vaping, strong smells, stress, damp housing and workplace exposure.
Ask about atopy and family history:
“Do you have eczema, hay fever or allergies?”
“Does asthma, eczema or hay fever run in the family?”
Also ask about smoking, vaping, cannabis or other inhaled substances, passive smoke exposure and occupational dust, fumes, chemicals or animals.
Impact on Life
Ask how asthma affects normal life:
“How much is this affecting your day-to-day life?”
“Is it affecting exercise, work, school, sleep, sport or social life?”
“Do you feel anxious or frightened when you become breathless?”
Breathlessness can be frightening, especially if the reliever inhaler is not helping as much as usual.
Ideas, Concerns and Expectations
Ask naturally:
“What do you think might be causing this flare-up?”
“Is there anything in particular you’re worried about?”
“What were you hoping we could do today?”
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 features suggest asthma?
Variable wheeze, cough, chest tightness or shortness of breath, recent exacerbations, poor preventer adherence or poor inhaler technique
Q4: 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.
Q5: 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.
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.