Shortness of Breath (Dyspnoea) – History Taking OSCE Guide

ByVarun
Shortness of Breath (dyspnoea) - History Taking OSCE Guide

Quick Revise

  • Respiratory: Asthma, COPD, Pneumonia, PE, Pneumothorax, ILD, Lung cancer
  • Cardiac: Heart failure, ACS, Arrhythmias, Valvular disease
  • Other: Anaemia, DKA, Renal failure, Anxiety
  • Use SOCRATES
  • Always document: “Shortness of breath for [duration].”
  • Remember: Always assess red flags first (SpO₂ <92%, haemodynamic instability, haemoptysis, stridor).
  • Timing: Intermittent (asthma, arrhythmia), Nocturnal (HF, asthma), Exertional (COPD, ILD, anaemia).
  • Exacerbating/Relieving: Orthopnoea/PND (HF), Exertion (all), Anxiety, Relief with rest/inhalers.
  • Severity: Use MRC Dyspnoea Scale (Grades 1–5).
  • Respiratory: Cough, sputum, wheeze, haemoptysis, chest pain, fever, weight loss.
  • Cardiac: Chest pain, palpitations, orthopnoea, PND, oedema, syncope.
  • Other: Fatigue, anxiety, hoarseness, recent infection.
  • Ideas – “What do you think is causing it?”
  • Concerns – “Is there anything you’re worried about?”
  • Expectations – “What were you hoping we could do?”
  • Respiratory: Asthma, COPD, TB, ILD.
  • Cardiac: IHD, HF, arrhythmia, hypertension.
  • Other: Anaemia, diabetes, renal disease, prior PE/DVT, cancer.
  • Thoracic surgery (lobectomy, pneumonectomy).
  • Cardiac surgery (CABG, valve replacement, pacemaker).
  • Recent major surgery → risk of PE/pneumonia.
  • Asthma, COPD, atopy
  • Early cardiac disease (MI, HF)
  • Clotting disorders (DVT/PE)
  • Respiratory: Inhalers, steroids.
  • Cardiac: Beta-blockers, ACEi, diuretics, amiodarone.
  • Other: Methotrexate, nitrofurantoin, chemotherapy.
  • Smoking: Pack years; risk for COPD, lung cancer, IHD.
  • Alcohol: Heavy use → arrhythmias, cardiomyopathy.
  • Occupation: Asbestos, silica, coal dust, farming/birds.
  • Lifestyle: Exercise tolerance, living situation/support.
  • Recent long-haul flight → PE.
  • Travel to TB-endemic areas.
  • Recent viral exposure (e.g. COVID, flu).

Background

Shortness of breath is a common and essential presenting complaint. Causes can be grouped by physiological system.

SystemAcute CausesChronic Causes
RespiratoryAsthma attack, COPD exacerbation, Pneumonia, Pulmonary embolism, PneumothoraxCOPD, Asthma, Bronchiectasis, Interstitial lung disease, Lung cancer
CardiovascularAcute coronary syndrome, Arrhythmia, Heart failure (acute pulmonary oedema), Cardiac tamponadeChronic heart failure, Valvular heart disease, Pulmonary hypertension
HaematologicalAcute haemorrhageAnaemia (iron deficiency, chronic disease)
MetabolicDiabetic ketoacidosis, Sepsis with lactic acidosisRenal failure with uraemic acidosis
NeuromuscularGuillain–Barré syndrome (acute crisis), Myasthenic crisisMotor neurone disease, Myasthenia gravis
PsychologicalPanic attackFunctional breathlessness, Anxiety disorders

Opening the Consultation

  • Wash your hands, introduce yourself, and confirm patient details.
  • Gain consent to take a history.
  • Check if the patient is comfortable talking.
  • If the patient is acutely unwell, prioritise the ABCDE assessment before taking a history.

Presenting Complaint

  • Open-ended question: “What has brought you in today?”
  • Document as: “Shortness of breath for [duration].”

History of Presenting Complaint

For shortness of breath, use SOCRATES:

None

Sudden (PE, pneumothorax) vs gradual (infection, HF).

None

None

SystemAssociated Symptoms
Respiratory– Cough (acute or chronic)
– Sputum production (purulent, mucoid, blood-stained)
– Wheeze
– Haemoptysis
– Pleuritic chest pain
– Fever, night sweats, rigours
– Weight loss, anorexia
Cardiac– Chest pain (central, crushing, exertional, or pleuritic)
– Palpitations
– Orthopnoea
– Paroxysmal nocturnal dyspnoea (PND)
– Peripheral oedema (ankle swelling)
– Syncope or presyncope
General/Other– Fatigue, reduced exercise tolerance
– Anxiety or panic symptoms (tingling, palpitations, fear of impending doom)
– Hoarseness or voice change (malignancy or nerve palsy)
– Recent upper respiratory tract infection (viral trigger for asthma/COPD exacerbation)

Elaborate on Sputum:

  1. Amount?
  2. Color?
  3. Change in colour?
  4. Any blood?

Asking about the timing of symptoms helps narrow down the underlying cause:

  • Intermittent
    • Suggests asthma (episodic wheeze, often with identifiable triggers) or paroxysmal arrhythmias (atrial fibrillation, SVT).
    • Important to ask about specific triggers (exercise, allergens, infections).
  • Nocturnal
    • Waking from sleep breathless (paroxysmal nocturnal dyspnoea, PND) is classic for left ventricular heart failure.
    • Nocturnal wheeze is typical of asthma, often worse in the early morning due to circadian variation in airway tone.
  • Exertional
    • Progressive exertional breathlessness is the hallmark of chronic conditions such as COPD, interstitial lung disease, anaemia, or heart failure.
    • Ask: “How far can you walk before becoming breathless?” (functional marker for severity).

Teaching tip

In OSCEs, if the patient describes exertional symptoms, always quantify with an activity (e.g. “one flight of stairs,” “walking to the shops”).

Lying flat (Orthopnoea)

Breathlessness when lying down, relieved by sitting upright.

Strongly suggests congestive heart failure due to redistribution of fluid to the lungs in the supine position.

Ask: “How many pillows do you sleep on at night?”

Exertion

Worsening breathlessness with physical activity is common across cardiac, respiratory, and haematological causes.

Important to distinguish whether it is sudden (PE, arrhythmia) or progressive (COPD, HF).

Anxiety

Stress and panic attacks can exacerbate subjective dyspnoea. Hyperventilation may mimic “air hunger.”

A diagnosis of exclusion — ensure you rule out organic causes first.

Rest

Relief at rest is common in asthma, COPD, and exertional angina.

Persistent symptoms even at rest usually indicate severe disease (advanced HF, pneumonia, acute pulmonary oedema).

Clinical pearl

Always ask whether symptoms improve or worsen with changes in position, rest, or medications (e.g., inhalers, GTN spray).

The Medical Research Council (MRC) Dyspnoea Scale is widely used in the UK to grade functional limitation due to breathlessness.

GradeDescription
1Not troubled by breathlessness except on strenuous exercise
2Short of breath when hurrying on the level or walking up a slight hill
3Walks slower than people of the same age on the level due to breathlessness, or has to stop for breath when walking at own pace
4Stops for breath after walking about 100 metres or after a few minutes on the level
5Walks slower than people of the same age on the level due to breathlessness, or has to stop for breath when walking at their own pace
  • Grades 3–5 are generally considered to have a clinically significant disability.
  • Used in primary care (e.g. annual COPD reviews) and research as a standardised severity tool.
  • In OSCEs, if a patient mentions exertional SOB, it’s excellent to say: “To quantify your symptoms, I’d like to use the MRC Dyspnoea Scale.”

NHS relevance: NICE recommends MRC grading for assessing COPD severity and deciding on pulmonary rehabilitation referral.

ICE (Ideas, Concerns, Expectations)

  • Ideas: “What do you think is causing your breathlessness?”
  • Concerns: “Is there anything you’re particularly worried about?”
  • Expectations: “What were you hoping we could do for you today?”

System Enquiry

A system enquiry ensures you don’t miss related or subtle symptoms. For shortness of breath, target the main systems:

  • Cough – acute or chronic; dry vs productive.
  • Sputum – colour (purulent in infection, pink frothy in pulmonary oedema, blood-stained in PE/malignancy).
  • Wheeze – suggests asthma or COPD.
  • Haemoptysis – think PE, TB, lung cancer, bronchiectasis.
  • Chest pain – pleuritic in PE/pneumonia, sharp in pneumothorax.
  • Night sweats/fever – infection (e.g. TB, pneumonia).
  • Weight loss – malignancy, chronic infection.
  • Chest pain – exertional angina, acute coronary syndrome.
  • Palpitations – arrhythmias (AF, SVT).
  • Orthopnoea – breathlessness when lying flat (heart failure).
  • Paroxysmal nocturnal dyspnoea (PND) – waking up breathless at night (LV failure).
  • Peripheral oedema – heart failure, pulmonary hypertension.
  • Syncope/presyncope – arrhythmia, aortic stenosis, PE.
  • Fatigue / reduced exercise tolerance – anaemia, chronic disease.
  • Hoarseness or voice change – malignancy (e.g. lung cancer with recurrent laryngeal nerve palsy).
  • Syncope/presyncope – arrhythmia, aortic stenosis, PE.
  • Anxiety/panic features – hyperventilation, tingling, sense of impending doom.

Past Medical History (PMHx)

Asking about past medical history is crucial because many chronic conditions predispose to SOB:

  • Asthma – note age of diagnosis, severity, hospital admissions, ITU/ventilation history.
  • COPD – smoking history, frequency of exacerbations, oxygen dependence.
  • Tuberculosis (TB) – scarring or bronchiectasis can cause chronic SOB.
  • Interstitial lung disease – progressive exertional SOB, especially in older patients.
  • Previous pneumothorax – risk of recurrence.
  • Ischaemic heart disease – angina, previous MI.
  • Heart failure – acute admissions, device therapy (e.g. pacemaker, ICD).
  • Arrhythmias – AF, SVT, flutter, VT.
  • Valvular disease – previous diagnosis of murmurs, valve replacements.
  • Hypertension – risk factor for LV hypertrophy and heart failure.
  • Anaemia – recurrent or chronic (e.g. from GI bleeding).
  • Diabetes mellitus – predisposes to ACS, HF, and infection.
  • Renal disease – fluid overload and metabolic acidosis.
  • Thromboembolic disease – prior DVT or PE (significant recurrence risk).
  • Cancer history – lung, breast, or other cancers → lung mets, malignant pleural effusion.

Surgical History

Past surgery can explain or complicate breathlessness.

  • Thoracic surgery – lobectomy or pneumonectomy may leave patients with reduced lung capacity.
  • Cardiac surgery – CABG, valve replacement, pacemaker insertion. Always ask about outcomes and complications.
  • Abdominal surgery – e.g. splenectomy (increased risk of infection, sepsis presenting with SOB).
  • Major orthopaedic surgery – risk of peri-operative DVT/PE.
  • Recent surgery – immobilisation, anaesthesia, or blood loss as immediate contributors to SOB.

Examiner Tip

“Any recent operations or procedures?” – always consider post-operative PE or pneumonia.

Drug History

  • Inhalers – salbutamol, salmeterol, steroids.
  • Oral steroids – ask about long-term use (risk of immunosuppression, osteoporosis).
  • Theophylline – toxicity may cause arrhythmias.
  • Beta-blockers – may trigger bronchospasm in asthmatics.
  • ACE inhibitors – can cause a chronic dry cough.
  • Diuretics – loop diuretics (furosemide) for HF; check for over-/underuse.
  • Amiodarone – associated with pulmonary fibrosis and thyroid dysfunction.
  • Methotrexate – pulmonary fibrosis.
  • Nitrofurantoin (long-term) – pulmonary fibrosis.
  • Chemotherapy agents – bleomycin (lung toxicity).
  • Biologics/immunosuppressants – infection risk.
  • All medications
    • Ask about adherence and side effects.
    • Always ask about recent antibiotic use (resistant pneumonia risk).

Allergies

  • Record drug allergies and nature of reaction (rash, anaphylaxis).

Family History

  • Asthma, COPD, atopy
  • Early cardiac disease (MI, HF)
  • Clotting disorders (DVT/PE)

Social History

  • Smoking history (pack years).
  • Alcohol use
    • Screen using units/week.
    • Heavy use is associated with cardiomyopathy and arrhythmias (AF).
  • Occupational exposures
    • Asbestos → mesothelioma, pleural plaques, asbestosis.
    • Silica dust (mining, construction) → silicosis, increased TB risk.
    • Coal dust → coal workers’ pneumoconiosis.
    • Farmers, bird exposure → hypersensitivity pneumonitis.
      • Always ask about the type of protective equipment and the duration of exposure.
      • NHS relevance: Many of these are reportable to occupational health and can lead to industrial disease claims.
  • Exercise tolerance
    • Useful functional marker (e.g. “How far can you walk before getting breathless?”).
  • Living situation/support
    • Who they live with, level of independence, and any carers.
    • Important in planning discharge if hospitalised.
  • Quantify in pack years (number of packs per day × years smoked).
  • Important risk factor for COPD, lung cancer, and ischaemic heart disease.
  • Also increases the risk of post-operative complications and recurrent chest infections.
  • Ask if they are still smoking or have quit; document nicotine replacement or vaping use.

OSCE Tip

Examiners expect you to mention smoking when taking any respiratory or cardiac history.

Travel History

  • Recent long-haul flights or immobility (PE risk).
  • TB endemic areas.
  • Recent infectious exposures (e.g. COVID, flu).

Closing the Consultation

  • Summarise key points back to the patient.
  • Check patient understanding and invite questions.
  • Explain the next steps, including examination, investigations, and initial management.
  • Thank the patient.

References

Varun Tyagi

CTF

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