Why Respiratory Histories Are High-Yield
Respiratory presentations account for a huge proportion of acute medical admissions in the UK. Cough, breathlessness, wheeze, and chest pain are among the most common presenting complaints in OSCEs — and they appear across every difficulty level. The challenge is that they share symptoms with cardiac, thromboembolic, and oncological conditions. Your history must actively discriminate between these.
💡 Tip
Before entering the station: Generate your top three differentials for the chief complaint and let them direct your SOCRATES questions from the very first answer.
SOCRATES for Respiratory Symptoms
Cough
| Question | Clinical relevance |
|---|---|
| Onset and duration | Acute < 3 weeks: URTI, pneumonia; subacute 3–8 weeks: post-infectious; chronic > 8 weeks: asthma, COPD, GORD, ACE inhibitor, malignancy |
| Dry or productive? | Productive = infection, bronchiectasis; dry = asthma, GORD, ACE inhibitor |
| Sputum colour and volume | Clear/white = viral; yellow/green = bacterial; rust-coloured = pneumococcal; large volumes = bronchiectasis |
| Haemoptysis | See red flags below |
| Timing | Morning = COPD/bronchiectasis; nocturnal = asthma, GORD; persistent = malignancy |
| Exacerbating factors | Exercise, allergens, cold air = asthma; lying flat = GORD |
Breathlessness
Start with onset and severity:
"When did you first notice the breathlessness? Did it come on suddenly or gradually over weeks?"
Quantify using the MRC Dyspnoea Scale:
| Grade | Description |
|---|---|
| 1 | Breathless only with strenuous exercise |
| 2 | Short of breath when hurrying on the flat or walking up a slight hill |
| 3 | Walks slower than most people on the flat; stops after a mile |
| 4 | Stops for breath after 100 metres or after a few minutes on the level |
| 5 | Too breathless to leave the house; breathless when dressing |
Then ask:
- "Has it been getting worse? Over days, weeks, or months?"
- "Is it there all the time, or does it come and go?"
- "Any wheeze alongside the breathlessness?"
- "Does it wake you at night?" (PND = cardiac; nocturnal asthma)
- "How many pillows do you sleep with?" (orthopnoea = cardiac, not respiratory)
💎 Clinical Pearl
Asking "how far can you walk on the flat before stopping?" is more clinically meaningful than quoting MRC grades. Patients understand walking distances better than grade descriptions — and you still get the functional information.
Wheeze
- "Is it there all the time or just in certain situations?"
- "Any triggers — pollen, animals, exercise, cold air, dust?"
- "Does it come on at work and improve on weekends or holidays?" (occupational asthma — crucial)
Chest Pain
- "Is the pain worse when you take a deep breath in?" (pleuritic = PE, pneumonia, pleuritis)
- "Is it sharp and localised to one spot?"
- Distinguish from cardiac pain using SOCRATES (see Cardiology History guide)
Red Flags — Never Miss
⚠️ Red Flag
Red flags triggering a 2-week wait cancer referral:
- Haemoptysis in any smoker over 40
- Unexplained cough lasting more than 3 weeks with any of: weight loss, hoarseness, dysphagia, persistent chest/shoulder pain, clubbing, new supraclavicular lymphadenopathy
- Recurrent chest infections in the same lobe
- CXR findings suggesting malignancy
Ask directly: "Have you coughed up any blood — even a small amount?"
Differentiating the Major Diagnoses
Asthma vs COPD
| Feature | Asthma | COPD |
|---|---|---|
| Age of onset | Usually < 40 | Usually > 40 |
| Smoking | Not required | Almost always (> 20 pack-years) |
| Symptoms | Variable, episodic | Progressive, persistent |
| Diurnal variation | Morning dipping common | Less pronounced |
| Triggers | Allergens, exercise, cold | Exertion, infections |
| Reversibility | Yes | Minimal |
| Family history | Often positive | Less significant |
💎 Clinical Pearl
The single most discriminating question between asthma and COPD: "Do your symptoms vary significantly from day to day, even hour to hour?" Variability strongly favours asthma. COPD is more fixed and progressive.
Pulmonary Embolism
- "Any swelling, redness, or tenderness in one leg?"
- "Any recent long flights, long car journeys, or periods of bed rest?"
- "Any recent surgery, hospitalisation, or immobilisation in a plaster cast?"
- "Are you on the contraceptive pill or HRT?"
- "Any personal or family history of blood clots?"
Pneumonia
- "Do you have a fever or feel feverish?"
- "Any shivers or rigors?"
- "Any pleuritic chest pain?"
- "Any confusion or disorientation?" (severity marker — CURB-65)
Lung Cancer — The Five Key Questions
- 1"Have you lost any weight without trying? How much over how long?"
- 2"Have you noticed any change in your voice — hoarseness?"
- 3"Any difficulty swallowing?"
- 4"Any new lumps in your neck?"
- 5"Any shoulder or arm pain?" (Pancoast tumour)
Smoking History — Get This Right
Never just ask "do you smoke?" — calculate pack-years:
"Do you smoke, or have you smoked in the past? How many cigarettes per day, and for how many years?"
Pack-years = cigarettes per day ÷ 20 × years smoked
20 cigarettes/day for 30 years = 30 pack-years
Also ask about:
- E-cigarettes and vaping
- Passive smoke exposure (childhood, occupational)
- Occupational exposure
🧠 Mnemonic
Occupational causes of respiratory disease — ABCDE:
- Asbestos → mesothelioma, asbestosis
- Beryllium → berylliosis
- Coal dust → pneumoconiosis
- Diisocyanates (spray paint, foam) → occupational asthma
- Extrinsic allergic alveolitis (farmers, pigeon fanciers, mouldy hay)
Drug History — Respiratory-Specific
Some medications cause or worsen respiratory disease:
- ACE inhibitors → dry cough (in up to 20% of patients)
- Beta-blockers → bronchospasm (contraindicated in asthma)
- Amiodarone → pulmonary fibrosis
- Nitrofurantoin → pulmonary fibrosis with long-term use
- NSAIDs → may worsen asthma in aspirin-sensitive patients
"Are you taking any heart tablets, blood pressure medications, or pain relief regularly?"
Systematic Review and Closing
Always close with:
- Family history: asthma, cystic fibrosis, alpha-1 antitrypsin deficiency
- Social history: pets (bird fancier's lung), travel (TB, atypical pneumonia), living conditions, damp housing
Summary and safety netting:
"To summarise, you've had a productive cough for six weeks with yellow sputum, associated with increasing breathlessness on exertion, and a 30 pack-year smoking history. Your exercise tolerance has dropped from a mile to about 100 metres over the last year."
"If you develop sudden severe breathlessness, cough up blood, or develop chest pain, please go straight to A&E."