History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Shortness of breath

  • Onset – how did it start?
  • Timeline and variability:
    • How long has this been going on?
    • Does this change throughout the day?
    • Is it intermittent or progressively getting worse?
  • Exacerbating factors?
    • Exertion?
    • Pollen/chemicals at work? – suggests asthma
    • Orthopnoea?
  • Alleviating factors?
  • Severity?
    • How far can they walk until they get short of breath?
    • Do they struggle walking upstairs?
    • Are they short of breath at rest?
  • Have they recently been ill?
  • Has this impacted their daily life and if so, how?

Review of systems

  • Screen for other cardiorespiratory symptoms:
    • Cough:
      • Dry or productive?
      • What are they coughing up?
        • Blood?
          • Fresh/bright red blood?
          • Dark clots or ground-up coffee?
        • What is the sputum like?
          • Offensive smell?
          • Colour? – may be white, yellow, green, or pink
    • Chest pain:
      • Assess using SOCRATES
    • Palpitations
    • Syncope
    • Wheezing
    • Stridor
    • Orthopnoea
    • Paroxysmal nocturnal dyspnoea
    • Peripheral oedema
  • Screen for red flags of malignancy:

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
    • Some medications that can cause shortness of breath include NSAIDs, methotrexate, beta-blockers, and amiodarone
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?
    • Atopy:
      • Eczema
      • Asthma
      • Hayfever
    • Heart disease
    • Lung problems including lung cancer

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

Physical examinations to perform are:

  • Vital signs may show:
    • Tachycardia, tachypnoea, and hypotension suggest shock
    • Pulsus paradoxus can suggest cardiac tamponade
    • Normal vital signs are not enough to exclude cardiorespiratory problems, as patients can still have normal oxygen saturations despite having an acute myocardial infarction, asthma, pulmonary embolism, COPD etc.
  • Respiratory examination may show:
    • Cyanosis
    • Clubbing:
    • Facial oedema:
      • Suggests anaphylaxis
    • Tracheal deviation:
    • Stridor:
      • Suggests upper airway obstruction (e.g. foreign body, anaphylaxis)
    • Wheezing:
      • Suggests asthma, COPD, anaphylaxis
    • Hoarseness:
      • Suggests laryngeal tumours, laryngeal palsy secondary to lung cancer
    • Barrel chest:
      • Suggests COPD
    • Unilateral dullness to percussion:
    • Unilateral decreased/absent breath sounds:
      • Suggests pneumothorax, pleural effusion, foreign body aspiration
    • Crackles:
      • Suggest heart failure, pneumonia, interstitial lung disease
  • Cardiovascular examination may show:
    • Elevated jugular venous pressure:
      • May suggest heart failure, COPD, tension pneumothorax, cardiac tamponade
    • Arrhythmia
    • Abnormal heart sounds/murmurs
    • Peripheral oedema

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
    • Full blood count (FBC):
      • May identify anaemia which can cause shortness of breath
      • May show leukocytosis suggesting infection
      • May show eosinophilia suggesting asthma
    • Urea and electrolytes (U&Es):
    • Liver function tests:
      • May show elevated bilirubin in liver failure or congestive heart failure
    • C-reactive protein:
      • Non-specific marker of inflammation, may be elevated
    • Venous/arterial blood gases:
      • May show derangements in pH, pO2, pCO2, bicarbonate, and base excess depending on the underlying cause
    • Cardiac enzymes (troponins):
      • If acute coronary syndrome is suspected
    • NT-proBNP:
      • Elevated in congestive heart failure
    • D-dimer:
    • Blood culture:
      • If severe pneumonia/sepsis suspected 
  • Orifice tests:
    • Sputum culture and gram stain:
      • May identify causative agent if infection suspected
    • Urinary Legionella antigen:
      • If Legionella pneumonia suspected
  • X-rays:
    • Chest X–ray:
      • To screen for pneumothorax
      • May show opacifications
      • May show signs of congestive heart failure (e.g. cardiomegaly)
  • ECGs:
    • ECG:
      • If chest pain or palpitations are present, or acute coronary syndrome suspected
  • Special tests:
    • Echocardiogram:
      • May show structural heart defects 
    • CT pulmonary angiography or V/Q scan:
      • For pulmonary embolism
    • High-resolution CT chest:
      • For pulmonary fibrosis
    • CT coronary angiography:
      • For angina or acute coronary syndrome
    • Spirometry:
      • For asthma or COPD

Differential Diagnoses (Acute/Subacute)

Pneumothorax

  • A history may reveal:
    • Shortness of breath is sudden in onset
    • Unilateral chest pain (often pleuritic)
    • There may be a history of pre-existing lung disease, tall and asthenic build, non-invasive ventilation 
  • A physical exam may reveal:
    • Unilaterally reduced/absent breath sounds, unilateral hyperresonance on percussion
  • Investigations may reveal:
    • Chest x-ray:
      • Collapsed lung and absent lung markings

Tension pneumothorax

  • A history may reveal:
    • Shortness of breath is sudden in onset
    • Unilateral chest pain (often pleuritic)
    • There may be a history of penetrating trauma (e.g. stabbing), pre-existing lung disease, tall and asthenic build, non-invasive ventilation 
  • A physical exam may reveal:
    • Unilaterally reduced/absent breath sounds, unilateral hyperresonance on percussion
    • Tracheal deviation away from the affected side, elevated jugular venous pressure, hypotension and tachycardia
  • Investigations may reveal:
    • Insertion of large bore cannula into 2nd or 5th intercostal space in the midclavicular line:
      • Hiss heard as decompression occurs
    • If suspected, urgent needle decompression should be performed – do not wait for imaging
      • A chest X-ray should not be waited for as this can delay treatment and lead to cardiac arrest

Pulmonary embolism

  • A history may reveal:
    • Sudden onset shortness of breath
    • Pleuritic chest pain may be present
    • Haemoptysis may be present
    • There may be a history of risk factors such as prothrombic state (e.g. pregnancy, inadequate coagulation, malignancy), prolonged immobilisation (e.g. long-haul flights), recent surgery, or oral oestrogens (e.g. combined oral contraceptive pill or combined oral hormone replacement therapy)
  • A physical exam may reveal:
    • Tachycardia, tachypnoea
    • Crackles and fever may be seen
  • Investigations may reveal:
    • Chest x-ray – done to screen for other pathologies such as pneumothorax
      • Usually clear
      • May show wedge-shaped opacification
    • ECG:
      • Sinus tachycardia is the most common feature
    • D-dimer:
      • Elevated
    • CT angiography or V/Q scan:
      • Diagnostic

Acute coronary syndrome

  • A history may reveal:
    • There may be chest pain or chest crushing/squeezing
    • The chest pain may radiate to the shoulder/jaw
    • Shortness of breath may happen in isolation in atypical presentations (especially in female patients and people with diabetes mellitus)
    • Associated pallor and diaphoresis
  • A physical exam may reveal:
    • Pallor, tachycardia, sweatiness, clamminess
  • Investigations may reveal:
    • ECG:
      • May show ST elevation, ST depression, Q wave changes or no changes
    • Cardiac enzymes (troponins):
      • Elevated in myocardial infarction
      • Normal in unstable angina
    • Coronary angiography:
      • Shows occlusion of coronary artery

Acute heart failure

  • A history may reveal:
    • Exertional shortness of breath that is worsening quickly
    • Orthopnoea, paroxysmal nocturnal dyspnoea
    • Ankle swelling
  • A physical exam may reveal:
    • Elevated jugular venous pressure, crackles, S3 gallop rhythm, peripheral oedema
  • Investigations may reveal:
    • Chest x-ray:
      • May show cardiomegaly, bilateral lobe shadowing, Kerley B-lines
    • ECG:
      • May show axis deviation
    • Echocardiogram:
      • Identifies structural abnormalities such as valve disease or wall motion abnormalities
    • NT-proBNP:
      • Elevated

Cardiac tamponade

  • A physical exam may reveal:
    • Beck’s triad – raised jugular venous pressure, hypotension, and muffled heart sounds
    • Pulsus paradoxus may be present – abnormally large drop in blood pressure during inspiration
  • Investigations may reveal:
    • ECG:
      • May show electrical alternans
    • Pericardiocentesis is urgently needed

Aortic dissection

  • A history may reveal:
    • Sudden severe ‘tearing’ or ‘ripping’ chest pain that may radiate to the back
    • There may be a history of hypertension
  • A physical exam may reveal:
    • >20 mmHg difference in systolic blood pressure between the arms
    • Pallor, tachycardia, hypotension
  • Investigations may reveal:
    • Chest x-ray:
      • Widened mediastinum
    • If stable: CT angiography:
      • Shows false lumen
    • If unstable: transoesophageal echocardiography
      • Shows double lumen or dissection flap

Acute asthma exacerbation

  • A history may reveal:
    • Progressively worsening wheezing, cough, chest tightness
    • Increased use of reliever inhaler
    • History of atopy (e.g. eczema/hayfever)
  • A physical exam may reveal:
    • Wheezing, tachycardia, tachypnoea, difficulty completing sentences, cyanosis, accessory muscle use, altered consciousness, coma depending on the severity
  • Investigations may reveal:
    • Peak expiratory flow rate (PEFR):
      • Decreased compared to best or predicted

Acute COPD exacerbation

  • A history may reveal:
    • Progressively worsening shortness of breath, cough, and wheezing
    • There may be increasing amounts of sputum production
    • A history of smoking
  • A physical exam may reveal:
    • Fever, crackles, wheezing, hypoxaemia
    • Cyanosis, chest hyper-expansion, facial plethora
  • Investigations may reveal:
    • Chest x-ray:
      • May show lung hyper-expansion and flattened hemidiaphragm
    • Arterial blood gas:
      • May show hypoxaemia with or without hypercapnia

Pneumonia

  • A history may reveal:
    • Subacute onset of fever, cough, shortness of breath, pleuritic chest pain
    • Cough may be productive
  • A physical exam may reveal:
    • Fever, tachycardia, crackles
    • Focal consolidation and dullness of percussion
  • Investigations may reveal:
    • Full blood count:
      • May show leukocytosis
    • Legionella urinary antigen:
      • For Legionella pneumonia
    • Blood cultures:
      • Identifies likely pathogen
    • Urea and electrolytes (U&Es):
      • Prognosis is worse if urea is elevated (CURB-65)
    • Chest x-ray:
      • Shows opacification

Sepsis

  • A history may reveal:
    • Features of a specific infection, fever, rigours, nausea, vomiting, confusion
    • Risk factors such as immunosuppression
  • A physical exam may reveal:
    • Tachycardia, tachypnoea, hypotension, fever, reduced urine output
    • Mottled skin, prolonged capillary refill time, altered mental state
  • Investigations may reveal:
    • Sepsis 6 – BUFALO:
      • Blood cultures
      • Urine output
      • Fluids – IV fluids
      • Antibiotics – broad-spectrum IV antibiotics
      • Lactate – serum lactate
      • Oxygen

Anaphylaxis

  • A history may reveal:
    • Exposure to an allergen such as food, stings from bees/wasps, or insect bites
    • Choking, shortness of breath, wheezing, rash, tongue and lip swelling
    • Nausea, vomiting, and diarrhoea may be present
  • A physical exam may reveal:
    • ABC:
      • Airway problems – stridor and hoarse voice
      • Breathing problems – wheezing and shortness of breath
      • Circulation problems – hypotension and tachycardia
  • Investigations may reveal:
    • Diagnosis is clinical but serum tryptase is measured to confirm anaphylaxis after treatment

Foreign body aspiration

  • A history may reveal:
    • Coughing and choking, ingestion of food
    • Recurrent pneumonia
  • A physical exam may reveal:
    • Unilateral wheezing, stridor, focal dullness to percussion
  • Investigations may reveal:
    • Chest x-ray:
      • May identify object

Arrhythmia

  • A history may reveal:
    • Shortness of breath with palpitations, weakness, pre-syncope or syncope
    • A history of heart disease
  • A physical exam may reveal:
    • Tachycardia or bradycardia, depending on arrhythmia
    • Pallor, sweating, peripheral oedema, altered mental state
  • Investigations may reveal:
    • ECG:
      • Identifies arrhythmia
    • Holter monitoring:
      • If initial ECG did not identify arrhythmia

Myocarditis

  • A history may reveal:
    • Usually a younger patient following a viral infection
    • Chest pain, shortness of breath, and arrhythmia
  • A physical exam may reveal:
    • Palpitations, crackles, elevated jugular venous pressure, tachycardia, S3 gallop
  • Investigations may reveal:
    • C-reactive protein:
      • Elevated
    • Cardiac troponins:
      • Elevated
    • NT-proBNP:
      • Elevated
    • ECG:
      • Tachycardia
      • Arrhythmia
      • ST elevation and T wave inversion

Pericarditis

  • A history may reveal:
    • Shortness of breath and pleuritic chest pain that may be worse when lying and improves when sitting or leaning forwards
    • Fever, malaise, non-productive cough
    • A history of viral infection, tuberculosis, chronic kidney disease, heart disease, radiotherapy, or malignancy 
  • A physical exam may reveal:
    • Tachycardia
    • Pericardial friction rub 
  • Investigations may reveal:
    • ECG:
      • Saddle-shaped ST elevation and PR depression
    • Echocardiography:
      • May show effusion and evidence of cardiac tamponade
    • C-reactive protein:
      • May be elevated
    • Troponins:
      • May be elevated

Panic attack

  • A history may reveal:
    • A choking sensation, discomfort, fear, anxiety
    • A history of anxiety, phobias, depression
  • A physical exam may reveal:
    • Tachycardia, tachypnoea, sweating
  • Investigations may reveal:
    • Clinical diagnosis
    • Arterial blood gas:
      • Respiratory alkalosis

Haemothorax

  • A history may reveal:
    • Blunt or penetrating chest trauma
  • A physical exam may reveal:
    • Hypotension, tachycardia, tachypnoea, shock
  • Investigations may reveal:
    • Chest x-ray:
      • Fluid in pleural space, blunting of costophrenic angle
    • Ultrasound:
      • Identifies fluid in pleural space suggestive of blood

Superior vena cava obstruction

  • A history may reveal:
    • Shortness of breath, swelling of face, neck, and arms, and periorbital oedema may be seen
    • Head fullness and headaches – worse in the mornings
    • Visual disturbances 
  • A physical exam may reveal:
    • Elevated jugular venous pressure, facial swelling and plethora
  • Investigations may reveal:
    • Chest x-ray:
      • Identifies tumour compressing superior vena cava
    • CT angiography:
      • Confirms superior vena cava narrowing

Carbon monoxide poisoning

A history may reveal:

  • Classically questions may hint at badly maintained housing (e.g. poor boiler function or furnaces)
  • Other household members may have similar symptoms
  • Pets may be unwell
  • Headaches are an early feature, nausea, vomiting, confusion, and weakness follow
  • A physical exam may reveal:
    • Tachypnoea, poor coordination, reduced consciousness
  • Investigations may reveal:
    • Oxygen saturation – may be normal
    • Arterial blood gases – carboxyhaemoglobin:
      • 3% or more in people who do not smoke
      • 10% in people who smoke 

Methaemoglobinaemia

  • A history may reveal:
    • The use of sulphonamides, nitrates (including recreational nitrates)
    • Headaches, nausea, anxiety
  • A physical exam may reveal:
    • Cyanosis, arrhythmia
    • Reduced oxygen saturations
  • Investigations may reveal:
    • Co-oximetry:
      • Elevated methaemoglobin
    • Arterial blood gases:
      • pO2 may be normal despite low oxygen saturation

Myasthenia gravis (myasthenic crisis)

  • A history may reveal:
    • Extraocular muscle weakness and diplopia, ptosis, dysphagia, and general weakness that is worse towards the end of the day
  • A physical exam may reveal:
    • May identify fatigue with repetitive movements
  • Investigations may reveal:
    • Pulmonary function test:
      • FVC low
    • Serum acetylcholine receptor antibodies (anti-AChR):
      • Usually positive
    • Muscle-specific tyrosine kinase antibodies (anti-MuSK):
      • Single-fibre EMG
    • CT chest in all new patients:
      • To detect thymoma

Differential Diagnoses (Chronic)

Asthma

  • A history may reveal:
    • Wheezing, cough, chest tightness
    • Increased use of reliever inhaler
    • History of atopy (e.g. eczema/hayfever)
  • A physical exam may reveal:
    • Wheezing, tachycardia, tachypnoea, difficulty completing sentences, cyanosis, accessory muscle use, altered consciousness, coma depending on the severity
  • Investigations may reveal:
    • Peak expiratory flow rate (PEFR):
      • Decreased compared to best or predicted
    • Spirometry with bronchodilator reversibility:
      • FEV1/FVC ratio 0.7 or less with reversibility
    • Fractional exhaled nitric oxide test (FeNO):
      • Increased

COPD

  • A history may reveal:
    • Shortness of breath, cough, and wheezing
    • Sputum production
    • A history of smoking
  • A physical exam may reveal:
    • Fever, crackles, wheezing, hypoxaemia
    • Cyanosis, chest hyper-expansion, facial plethora
  • Investigations may reveal:
    • Spirometry with bronchodilator reversibility:
      • FEV1/FVC ratio 0.7 or less without reversibility

Stable Angina

  • A history may reveal:
    • Dull chest pain or discomfort that is relieved with rest
    • No associated nausea, vomiting, pallor, shortness of breath 
  • A physical exam may reveal:
    • Nothing – an examination may be normal
  • Investigations may reveal:
    • ECG:
      • No acute changes
    • Troponins
      • Not elevated
    • CT coronary angiography:
      • Confirms diagnosis

Bronchiectasis

  • A history may reveal:
    • Chronic cough productive of foul, offensive, copious amounts of sputum
    • Shortness of breath
    • Recurrent infection
    • Severe infection in childhood
  • A physical exam may reveal:
    • Crackles, wheezing, clubbing
  • Investigations may reveal:
    • Chest x-ray:
      • Thickened airways
    • High-resolution CT chest:
      • Tram-tracking and bronchial dilation

Interstitial Lung Disease

  • A history may reveal:
    • Slow, progressive shortness of breath and dry cough
    • There may be a history of exposure to chemicals, radiotherapy, chemotherapy, some drugs (e.g. nitrofurantoin, methotrexate, amiodarone), asbestos, tuberculosis, ankylosing spondylitis, silicosis, sarcoidosis
  • A physical exam may reveal:
    • Dry crackles, clubbing
  • Investigations may reveal:
    • Pulmonary function tests:
      • Shows restrictive pattern
    • High-resolution CT scan:
      • Ground glass appearance

Hypersensitivity Pneumonitis

  • A history may reveal:
    • May present acutely within 4-8 hours after exposure with fever, chills, cough (may be productive)
    • May present more slowly weeks-months after exposure with lethargy, productive cough, weight loss
    • A causative trigger may be identified such as pet birds
  • A physical exam may reveal:
    • Crackles
  • Investigations may reveal:
    • Chest x-ray:
      • May show fibrosis
    • CT chest:
      • May show fibrosis

Lung Cancer

  • A history may reveal:
    • Cough, haemoptysis, unexplained weight loss, hoarseness, chest pain
    • Features of paraneoplastic syndromes
  • A physical exam may reveal:
    • Focal wheezing, dullness, decreased breath sounds
  • Investigations may reveal:
    • Chest x-ray:
      • Mass present
    • CT chest:
      • Mass present
    • Biopsy:
      • Histologically confirms lung cancer

Pulmonary tuberculosis (TB)

  • A history may reveal:
    • Cough, fever, weight loss, night sweats, haemoptysis
    • HIV/immunosuppression
    • Travel to an endemic area
  • A physical exam may reveal:
    • Fever, tachypnoea
  • Investigations may reveal:
    • Chest x-ray:
    • Sputum culture:
      • Diagnostic

Pleural Effusion

  • A history may reveal:
    • Progressive shortness of breath and a dull ache may be present
  • A physical exam may reveal:
    • Dullness to percussion, reduced breath sounds, reduced chest expansion
  • Investigations may reveal:
    • Chest x-ray:
      • Shows effusion and blunting of costophrenic angles

Anaemia

  • A history may reveal:
    • Shortness of breath on exertion, chest pain, palpitations, lethargy, pre-syncope/syncope 
  • A physical exam may reveal:
  • Investigations may reveal:
    • Full blood count:
      • Haemoglobin low

Sarcoidosis

  • A history may reveal:
    • Fever, arthritis, erythema nodosum, weight loss, malaise
  • A physical exam may reveal:
    • Wheezing, dry crackles
  • Investigations may reveal:
    • Chest x-ray:
      • Bilateral hilar lymphadenopathy
    • Serum ACE:
      • Elevated
    • Serum calcium:
      • Elevated
    • Lung biopsy:
      • Non-caseating granuloma

Hypertrophic Obstructive Cardiomyopathy

  • A history may reveal:
    • Syncope following exercise, angina, exertional shortness of breath
    • There may be a family history of sudden cardiac death
  • A physical exam may reveal:
    • Ejection systolic murmur louder with Valsalva manoeuvre and quieter when squatting, pansystolic murmur, double apex beat
  • Investigations may reveal:
    • ECG:
      • Shows axis deviation and left ventricular hypertrophy
    • Echocardiogram:
      • MR SAM ASH:

Mesothelioma

  • A history may reveal:
    • Asbestos exposure around 20-40 years before the onset of symptoms 
    • Dry cough, fatigue, fever, weight loss, night sweats
  • A physical exam may reveal:
    • Decreased breath sounds, dullness to percussion on the affected side due to pleural effusion
  • Investigations may reveal:
    • Chest x-ray:
      • May show pleural thickening, pleural effusion
    • CT chest:
      • Shows pleural thickening

Phaeochromocytoma

  • A history may reveal:
    • Episodic headaches, sweating, tachycardia and palpitations, and feeling panicky
  • A physical exam may reveal:
    • Severe hypertension
  • Investigations may reveal:
    • 24-hour urinary metanephrines:
      • Elevated

Kyphoscoliosis and pectus excavatum

  • A history may reveal:
    • Pectus excavatum, poor posture, neuromuscular disease, vertebral body destruction (e.g. fractures), ankylosing spondylitis
  • A physical exam may reveal:
    • Pectus excavatum may be seen, kyphosis may be seen, scoliosis may be seen
  • Investigations may reveal:
    • Spinal x-ray:
      • Shows abnormal spine/sternum shape

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