Dyspnoea

1. Overview

Dyspnoea, or shortness of breath, is a common OSCE presentation with a broad differential diagnosis. The key task is to determine whether the patient is acutely unstable, identify immediately life-threatening causes, and then separate respiratory, cardiac, metabolic, haematological and psychological causes.

In an OSCE, examiners expect a structured assessment of onset, severity, triggers, associated symptoms, past cardiorespiratory disease, risk factors and functional limitation. The candidate should also demonstrate safety by mentioning ABCDE assessment, oxygen saturation, ECG, chest X-ray and urgent escalation when appropriate.

Important life-threatening causes

• Acute coronary syndrome.
• Acute heart failure or pulmonary oedema.
• Pulmonary embolism.
• Pneumothorax, especially tension pneumothorax.
• Severe asthma attack.
• Acute COPD exacerbation with respiratory failure.
• Pneumonia or sepsis.
• Anaphylaxis.
• Metabolic acidosis, including diabetic ketoacidosis.
• Severe anaemia.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their breathing symptoms.
• Gain consent.
• Check whether the patient is too breathless to speak.
• If the patient is acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask the patient to describe the shortness of breath in their own words.
• Clarify when it started.
• Ask whether it was sudden or gradual.
• Ask whether it is constant or intermittent.
• Ask whether it is getting better, worse or staying the same.
• Ask whether this has happened before.
• Ask how severe it is compared with their normal baseline.

Dyspnoea history

• Onset: sudden onset suggests PE, pneumothorax, acute asthma, ACS or acute heart failure.
• Duration: minutes, hours, days, weeks or months.
• Progression: worsening breathlessness may suggest infection, heart failure, COPD progression or malignancy.
• Triggers: exertion, allergens, cold air, exercise, lying flat, emotional stress or occupational exposure.
• Relieving factors: rest, inhalers, sitting upright, oxygen, diuretics or antibiotics.
• Exercise tolerance: distance walked, stairs climbed and comparison with previous baseline.
• Impact on activities of daily living.
• Ability to speak in full sentences.

Orthopnoea and paroxysmal nocturnal dyspnoea

• Ask whether breathlessness is worse lying flat.
• Ask how many pillows the patient sleeps with.
• Ask whether they wake at night gasping for breath.
• Orthopnoea and paroxysmal nocturnal dyspnoea suggest heart failure.

Respiratory associated symptoms

• Cough.
• Sputum production and colour.
• Haemoptysis.
• Wheeze.
• Chest tightness.
• Pleuritic chest pain.
• Fever or rigors.
• Night sweats.
• Weight loss.
• Recent upper respiratory tract symptoms.

Cardiac associated symptoms

• Chest pain or pressure.
• Palpitations.
• Syncope or presyncope.
• Peripheral oedema.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Reduced exercise tolerance.
• Fatigue.

Pulmonary embolism risk factors

• Recent surgery or hospital admission.
• Recent immobilisation.
• Long-distance travel.
• Previous DVT or PE.
• Active cancer.
• Pregnancy or postpartum state.
• Oestrogen-containing contraception or hormone therapy.
• Thrombophilia.
• Unilateral calf pain or swelling.

Asthma and COPD history

• Known diagnosis of asthma or COPD.
• Current inhalers and adherence.
• Frequency of reliever inhaler use.
• Recent increase in inhaler use.
• Previous hospital admissions.
• Previous ICU admission or ventilation.
• Known triggers.
• Smoking history.
• Occupational exposure.

Infection history

• Fever.
• Productive cough.
• Pleuritic chest pain.
• Confusion or reduced consciousness.
• Recent sick contacts.
• Recent travel.
• Immunosuppression.
• Vaccination history if relevant.

Anaemia and systemic symptoms

• Fatigue.
• Dizziness.
• Palpitations.
• Pallor noticed by patient or family.
• Heavy menstrual bleeding.
• PR bleeding or melaena.
• Poor diet.
• Known chronic disease.

Past medical history

• Asthma.
• COPD.
• Interstitial lung disease.
• Previous pneumonia or tuberculosis.
• Heart failure.
• Ischaemic heart disease.
• Valvular heart disease.
• Arrhythmias.
• Previous DVT or PE.
• Anaemia.
• Chronic kidney disease.
• Diabetes mellitus.
• Malignancy.

Drug history and allergies

• Current regular medications.
• Inhalers: reliever, preventer and long-acting bronchodilators.
• Diuretics.
• Beta-blockers.
• ACE inhibitors, which may cause cough.
• Anticoagulants.
• Amiodarone, which can cause lung toxicity.
• Chemotherapy or immunosuppressive medications.
• Recent antibiotics or steroids.
• Drug allergies and reaction.

Family history

• Asthma or atopy.
• Thromboembolic disease.
• Premature ischaemic heart disease.
• Cardiomyopathy.
• Sudden cardiac death.
• Inherited lung disease if relevant.

Social history

• Smoking history in pack-years.
• Vaping.
• Alcohol intake.
• Recreational drug use.
• Occupation and exposure to dust, asbestos, chemicals, birds or mould.
• Pets and home environment.
• Exercise tolerance and baseline functional status.
• Living situation and support.
• Recent travel.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the breathlessness.
• Ask what they are most worried about.
• Ask what they were hoping would happen today.
• Acknowledge distress and reassure that their breathing will be assessed carefully.

Red flags

• Severe breathlessness at rest.
• Unable to speak in full sentences.
• Central cyanosis.
• Low oxygen saturation.
• Chest pain with breathlessness.
• Syncope or collapse.
• Haemoptysis.
• Unilateral leg swelling.
• Confusion or drowsiness.
• Hypotension or signs of shock.
• Silent chest in asthma.
• Rapidly worsening symptoms.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine them, check oxygen saturation and arrange urgent investigations if indicated.

3. Physical Examination

The examination should be guided by severity. If the patient is acutely breathless, begin with an ABCDE assessment. If stable, perform a focused respiratory and cardiovascular examination, with targeted assessment for DVT, anaemia and systemic disease.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient is comfortable to proceed.
• Position the patient sitting upright or at 45 degrees.
• Ensure adequate exposure of the chest while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment: is the patient unstable?

• Look from the end of the bed: is the patient comfortable, distressed, breathless, cyanosed, sweaty or confused?
• Assess whether the patient can speak in full sentences.
• Look for use of accessory muscles.
• Look for oxygen therapy, nebulisers, inhalers, cardiac monitor, IV lines or resuscitation equipment.
• If the patient is acutely unwell, state that you would perform ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether the airway is patent.
• Breathing: check respiratory rate, oxygen saturation, work of breathing, chest expansion, percussion and auscultation.
• Circulation: check pulse, blood pressure, capillary refill, ECG monitoring, IV access and signs of shock.
• Disability: assess consciousness level, pupils if indicated and capillary blood glucose.
• Exposure: check temperature, inspect for rashes, leg swelling, trauma and signs of infection while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation on air or oxygen.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Pain score if chest pain is present.
• Peak expiratory flow if asthma is suspected and patient is able to perform it.

Hands

• Inspect for peripheral cyanosis.
• Look for clubbing, which may suggest lung cancer, bronchiectasis, interstitial lung disease or cyanotic heart disease.
• Look for nicotine staining.
• Look for peripheral oedema.
• Check for fine tremor from beta-agonist use.
• Look for flapping tremor suggesting carbon dioxide retention.
• Assess capillary refill time.
• Check for palmar pallor suggesting anaemia.

Pulse and blood pressure

• Assess pulse rate.
• Assess rhythm.
• Assess volume.
• Tachycardia may occur in PE, sepsis, asthma, anxiety, anaemia or heart failure.
• An irregularly irregular pulse may suggest atrial fibrillation.
• Measure blood pressure.
• Hypotension may suggest shock, massive PE, sepsis or severe cardiac disease.

Face, mouth and eyes

• Look for central cyanosis on the tongue.
• Look for conjunctival pallor suggesting anaemia.
• Look for pursed-lip breathing in COPD.
• Look for signs of steroid use if chronic respiratory disease is present.
• Look for facial swelling or urticaria if anaphylaxis is suspected.

Neck

• Assess jugular venous pressure at 45 degrees.
• Raised JVP may suggest right heart failure, fluid overload, pulmonary hypertension, massive PE or tension pneumothorax.
• Check tracheal position.
• Tracheal deviation may occur in tension pneumothorax, large pleural effusion or lung collapse.
• Assess cervical lymphadenopathy if malignancy or infection is suspected.

Chest inspection

• Inspect chest shape, including barrel chest suggesting COPD.
• Look for scars from thoracic surgery.
• Look for chest wall deformity.
• Assess respiratory rate and pattern.
• Look for accessory muscle use.
• Look for intercostal recession.
• Look for asymmetrical chest movement.
• Look for visible pulsations or pacemaker if cardiac disease is suspected.

Palpation

• Assess chest expansion anteriorly or posteriorly.
• Reduced unilateral expansion may suggest pneumothorax, pleural effusion or consolidation.
• Assess tactile vocal fremitus if relevant.
• Palpate for chest wall tenderness if musculoskeletal pain is possible.
• Palpate apex beat if cardiac disease or heart failure is suspected.
• Assess for heaves or thrills if cardiac examination is being performed.

Percussion

• Percuss the chest comparing side to side.
• Hyperresonance may suggest pneumothorax or hyperinflation.
• Dullness may suggest pleural effusion, consolidation, collapse or mass.
• Percuss lung bases carefully.

Auscultation

• Auscultate all lung zones comparing side to side.
• Listen for wheeze, suggesting asthma, COPD or bronchospasm.
• Listen for crackles, suggesting pneumonia, pulmonary oedema, fibrosis or bronchiectasis.
• Listen for reduced breath sounds, suggesting pneumothorax, pleural effusion or collapse.
• Listen for bronchial breathing, suggesting consolidation.
• Assess vocal resonance if consolidation or effusion is suspected.
• A silent chest in severe asthma is a medical emergency.

Cardiovascular examination

• Assess JVP.
• Palpate apex beat.
• Auscultate heart sounds.
• Listen for murmurs, especially if valvular disease is suspected.
• Listen for third heart sound suggesting heart failure.
• Auscultate lung bases for crackles suggesting pulmonary oedema.
• Check for peripheral oedema.

Calves and DVT assessment

• Inspect both calves for asymmetry.
• Look for unilateral swelling.
• Look for erythema.
• Ask about tenderness before palpating.
• Assess for calf tenderness if clinically appropriate.
• DVT signs support possible pulmonary embolism but may be absent.

Abdominal and systemic examination if indicated

• Check for hepatomegaly and ascites if heart failure or liver disease is suspected.
• Assess for abdominal tenderness if metabolic or abdominal cause is suspected.
• Look for cachexia or lymphadenopathy if malignancy or chronic disease is suspected.
• Check temperature and signs of sepsis if infection is suspected.

Specific findings to mention in dyspnoea OSCE

• Asthma may show wheeze, tachypnoea and reduced peak flow; severe asthma may have a silent chest.
• COPD may show pursed-lip breathing, barrel chest, reduced breath sounds, wheeze and hyperinflation.
• Heart failure may show raised JVP, displaced apex beat, S3, basal crackles and peripheral oedema.
• Pneumonia may show fever, crackles, bronchial breathing and dullness to percussion.
• Pneumothorax may show reduced expansion, hyperresonance and reduced breath sounds.
• Pleural effusion may show reduced expansion, stony dull percussion and reduced breath sounds.
• PE may show tachycardia, hypoxia, pleuritic pain and signs of DVT, but examination may be non-specific.
• Anaemia may show pallor, tachycardia and flow murmur.

To complete the examination

To complete my examination, I would review observations, perform a 12-lead ECG, check oxygen saturation and peak flow if appropriate, request blood tests, obtain a chest X-ray, and arrange further investigations such as arterial blood gas, BNP, echocardiography or CT pulmonary angiography depending on the suspected diagnosis. I would escalate urgently if the patient is hypoxic, unstable or has features of a life-threatening cause.

4. Differential Diagnosis

Respiratory causes

• Asthma exacerbation.
• COPD exacerbation.
• Pneumonia.
• Pulmonary embolism.
• Pneumothorax.
• Pleural effusion.
• Interstitial lung disease.
• Lung cancer.
• Bronchiectasis.

Cardiac causes

• Acute heart failure.
• Chronic heart failure.
• Acute coronary syndrome.
• Arrhythmia, especially atrial fibrillation.
• Valvular heart disease.
• Pericardial effusion or tamponade.
• Cardiomyopathy.

Haematological and metabolic causes

• Anaemia.
• Metabolic acidosis, including diabetic ketoacidosis.
• Sepsis.
• Renal failure with fluid overload.
• Thyrotoxicosis.

Other causes

• Anxiety or panic attack.
• Obesity or deconditioning.
• Neuromuscular weakness.
• Pregnancy-related dyspnoea.
• Drug-induced lung disease.

5. Investigations

Bedside tests

• Oxygen saturation.
• Respiratory rate and full observations.
• Peak expiratory flow if asthma is suspected.
• 12-lead ECG.
• Capillary blood glucose.
• Urine dip if clinically relevant.

Blood tests

• Full blood count to assess anaemia or infection.
• Urea and electrolytes.
• CRP if infection or inflammation is suspected.
• Troponin if ACS is suspected.
• BNP or NT-proBNP if heart failure is suspected.
• D-dimer only when PE is possible and pre-test probability supports testing.
• Arterial or venous blood gas if hypoxic, severely breathless or at risk of respiratory failure.
• Thyroid function tests if thyrotoxicosis is suspected.

Imaging and specialist tests

• Chest X-ray.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• Echocardiogram if heart failure, valvular disease or pulmonary hypertension is suspected.
• Spirometry for chronic obstructive or restrictive lung disease when stable.
• High-resolution CT chest if interstitial lung disease or bronchiectasis is suspected.
• Sputum culture if productive cough and infection suspected.
• Blood cultures if septic.

Important points

• Do not delay urgent treatment in an unstable patient while waiting for investigations.
• A normal chest X-ray does not exclude PE or asthma.
• PE can have non-specific examination findings.
• ABG is useful in severe asthma, COPD exacerbation, hypoxia or suspected type 2 respiratory failure.

6. Management

Management depends on the likely cause and severity. In an OSCE, always begin with assessment of stability, oxygenation and the need for urgent senior help.

Immediate approach

1. Assess ABCDE if the patient is acutely unwell.
2. Call for senior help if severe breathlessness, hypoxia, shock, confusion or exhaustion is present.
3. Sit the patient upright.
4. Give oxygen if hypoxaemic or according to local oxygen target protocol.
5. Attach monitoring if unstable.
6. Obtain IV access and take bloods.
7. Perform ECG and chest X-ray early.
8. Treat the likely cause while continuing reassessment.

If asthma exacerbation is suspected

• Assess severity using symptoms, respiratory rate, oxygen saturation, pulse and peak flow.
• Give oxygen if hypoxaemic according to local target saturations.
• Give inhaled or nebulised salbutamol.
• Add ipratropium bromide if severe or poor response.
• Give systemic corticosteroids according to local protocol.
• Escalate urgently if silent chest, exhaustion, confusion, cyanosis or poor response.

If COPD exacerbation is suspected

• Assess oxygen saturation and risk of carbon dioxide retention.
• Give controlled oxygen to target saturation according to local protocol.
• Give bronchodilators.
• Consider systemic corticosteroids.
• Consider antibiotics if increased sputum purulence or infective features.
• Check blood gas if severe or drowsy.
• Consider non-invasive ventilation if type 2 respiratory failure and appropriate.

If heart failure is suspected

• Sit the patient upright.
• Give oxygen if hypoxaemic.
• Assess fluid status and blood pressure.
• Give diuretics such as furosemide according to local protocol.
• Treat precipitating causes such as ACS, arrhythmia, infection or poor adherence.
• Arrange ECG, chest X-ray, BNP and echocardiography.
• Escalate if pulmonary oedema, hypoxia or shock is present.

If pulmonary embolism is suspected

• Assess haemodynamic stability.
• Use a validated pre-test probability tool according to local pathway.
• Request D-dimer or CTPA depending on probability.
• Start anticoagulation if PE is likely and bleeding risk is acceptable.
• Massive PE with shock requires urgent senior and specialist input.

If pneumonia is suspected

• Assess severity using observations and clinical judgement.
• Give oxygen if hypoxaemic.
• Obtain chest X-ray and blood tests.
• Give antibiotics according to local guideline.
• Give fluids if dehydrated or septic, with caution in heart failure.
• Escalate if sepsis, hypoxia, confusion or respiratory failure is present.

Long-term management

• Treat and optimize the underlying condition.
• Smoking cessation.
• Vaccination advice where relevant.
• Inhaler technique review for asthma or COPD.
• Pulmonary rehabilitation for COPD where appropriate.
• Heart failure medication optimization if relevant.
• Safety-net advice for worsening breathlessness, chest pain, syncope, cyanosis or confusion.
• Arrange follow-up with primary care, respiratory medicine or cardiology depending on diagnosis.

7. Examiner Questions

1. What are the life-threatening causes of dyspnoea?
2. How would you assess severity in a breathless patient?
3. What features suggest pulmonary embolism?
4. What features suggest heart failure?
5. What features suggest asthma exacerbation?
6. What is the significance of a silent chest?
7. When would you request an arterial blood gas?
8. What investigations would you order for acute dyspnoea?
9. What are the causes of type 1 respiratory failure?
10. What are the causes of type 2 respiratory failure?
11. How do you manage acute pulmonary oedema?
12. How do you manage an acute asthma attack?
13. What oxygen target would you use in COPD?
14. What discharge advice would you give after a COPD or asthma exacerbation?

Suggested short answers

8. OSCE Pearls

• Start by checking whether the patient can speak in full sentences.
• Always ask about onset: sudden dyspnoea is more concerning for PE, pneumothorax or acute cardiac disease.
• Ask about orthopnoea and paroxysmal nocturnal dyspnoea for heart failure.
• Ask about wheeze, triggers and inhaler use for asthma or COPD.
• Ask about pleuritic chest pain, haemoptysis and calf swelling for PE.
• Ask about fever, cough and sputum for pneumonia.
• Ask about smoking and occupational exposure.
• Do not forget anaemia as a cause of breathlessness.
• Mention oxygen saturation, ECG and chest X-ray early.
• A silent chest in asthma is a red flag.
• PE can have a relatively normal chest examination.
• Always escalate if the patient is hypoxic, confused, exhausted or hypotensive.

9. Example Presentation to Examiner

10. References

• BTS/SIGN British guideline on the management of asthma.
• GOLD Report: Global strategy for prevention, diagnosis and management of COPD.
• NICE guidance on chronic obstructive pulmonary disease and heart failure.
• NICE guidance on pneumonia and venous thromboembolic disease.
• Local hospital emergency medicine, respiratory and cardiology protocols.