COPD History Taking OSCE, Symptoms, Severity, and Examiner Answers

Why COPD History Is Tested

COPD is the third most common cause of death worldwide and one of the most prevalent long-term conditions in the UK. It appears in respiratory history stations, chronic disease management scenarios, and as the context for examination or prescribing stations. Distinguishing COPD from asthma and accurately grading severity on history is a core clinical skill.

Opening and Establishing the Presenting Complaint

Start open:

• "What's brought you in today?"
• "Can you tell me a bit more about your breathing?"

Most COPD stations will present with one of: worsening breathlessness, increased cough and sputum, or an acute exacerbation.

Breathlessness: The MRC Dyspnoea Scale

Quantify breathlessness using the Medical Research Council (MRC) Dyspnoea Scale. This is directly assessed by examiners.

Ask: "How far can you walk on the flat before you have to stop for breath?" and "Can you climb stairs?"

Core Symptom Questions

Cough

• "Do you have a cough? Is it dry or does it bring up phlegm?"
• "What colour is the phlegm? Has it changed recently?"
• Yellow or green sputum suggests infective exacerbation
• Haemoptysis (blood) requires urgent investigation to exclude cancer

Wheeze

• "Do you ever hear a whistling sound when you breathe?"
• Wheeze in COPD tends to be persistent; in asthma it is more variable

Exacerbations

• "How many times in the last year have you needed antibiotics or steroids for your chest?"
• "Have you ever been admitted to hospital because of your chest?"
• Frequency of exacerbations is a key prognostic marker and informs treatment escalation
• Two or more exacerbations per year = frequent exacerbator phenotype

Exercise Tolerance

• "What can you do now that you couldn't do six months ago?"
• "Are you able to manage at home?"

Smoking History: Always Calculate Pack-Years

COPD is almost entirely caused by smoking. Calculate pack-years:

Pack-years = (cigarettes per day / 20) x years smoked

Example: 20 cigarettes per day for 30 years = 30 pack-years.

Ask:

• "Do you or did you smoke?"
• "How many cigarettes a day?"
• "How many years did you smoke for?"
• "Have you stopped? If so, when?"

Also ask about:

• Occupational dust and fume exposure (miners, construction workers, farmers)
• Alpha-1 antitrypsin deficiency (consider in younger patients with emphysema or non-smokers)

Differentiating COPD from Asthma

Current Treatment and Compliance

Explore what the patient is already using:

• "What inhalers are you on?"
• "Can you show me how you use them?" (inhaler technique is commonly poor)
• "Are you taking them every day or only when you're breathless?"
• "Are you on any tablets for your lungs?"
• "Have you had a pulmonary rehabilitation course?"

Home Oxygen and Nebulisers

• "Do you use oxygen at home? How many hours a day?"
• Long-term oxygen therapy (LTOT) is indicated if PaO2 is consistently below 7.3 kPa on air
• "Do you have a nebuliser at home?"

Impact and Functional Assessment

• "What does a typical day look like for you?"
• "Are you able to dress yourself, cook, shower?"
• "Have you needed any help at home?"
• "How has this affected your mood?"

Social History

• Occupation (and whether still working)
• Home environment: stairs, distance from shops
• Carers or support network
• Smoking status at home (second-hand smoke)

Systemic Review: Complications of COPD

Always ask about:

• Ankle swelling (cor pulmonale: right heart failure from chronic hypoxia)
• Weight loss (sign of severe disease or coexisting cancer)
• Haemoptysis (lung cancer: 10x more common in COPD patients who smoke)
• Cyanosis and headaches (chronic hypercapnia)

Frequently Asked Questions

"How do you classify COPD severity and what does spirometry show?"

COPD severity is classified by post-bronchodilator FEV1 as a percentage of predicted, using the GOLD classification. GOLD 1 (mild): FEV1 80% or above predicted; GOLD 2 (moderate): FEV1 50-79%; GOLD 3 (severe): FEV1 30-49%; GOLD 4 (very severe): FEV1 below 30%. All require an FEV1/FVC ratio below 0.70 post-bronchodilator to confirm obstructive defect. Unlike asthma, this obstruction is not fully reversible after a bronchodilator. The MRC dyspnoea scale and exacerbation frequency are also used alongside spirometry to guide treatment decisions, particularly the choice between LABA/LAMA combinations and triple therapy with inhaled corticosteroids.

"What is a COPD exacerbation and what triggers it?"

A COPD exacerbation is an acute worsening of respiratory symptoms beyond day-to-day variation, requiring a change in treatment. The defining symptoms are worsening breathlessness, increased sputum volume, and change in sputum colour (purulence). The most common triggers are respiratory infections: approximately 50% are caused by bacteria (Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis), 30% by viruses (rhinovirus, influenza, RSV), and 20-30% have no identifiable trigger. Environmental triggers include air pollution and cold weather. Treatment of an exacerbation includes short-acting bronchodilators, a 5-day course of prednisolone 30 mg, and antibiotics if sputum is purulent or the patient is severely unwell.

"What is cor pulmonale and what symptoms would you ask about in the history?"

Cor pulmonale is right heart failure secondary to chronic lung disease, most commonly COPD. Chronic hypoxia causes pulmonary vasoconstriction, leading to pulmonary hypertension, right ventricular hypertrophy, and eventually right ventricular failure. In the history, ask about bilateral ankle swelling (pitting oedema from venous congestion), increasing breathlessness despite treatment, fatigue, and reduced exercise tolerance. Associated signs on examination include elevated JVP, peripheral oedema, right ventricular heave, and a loud pulmonary second heart sound. The ECG may show right axis deviation, right bundle branch block, or P pulmonale. Treatment includes LTOT (the only intervention shown to improve survival in hypoxaemic COPD), diuretics for oedema, and optimising COPD management.

"What is long-term oxygen therapy and who is eligible?"

Long-term oxygen therapy (LTOT) is oxygen delivered for at least 15 hours per day, including overnight, via a concentrator at home. It is indicated when: resting PaO2 is persistently below 7.3 kPa on two measurements at least 3 weeks apart when the patient is clinically stable; or PaO2 is 7.3-8.0 kPa with complications including pulmonary hypertension, peripheral oedema, polycythaemia (haematocrit above 55%), or nocturnal hypoxaemia. LTOT is the only medical treatment proven to reduce mortality in COPD, by an approximately 30% reduction in 5-year mortality compared to 12-hour therapy. Patients must be assessed while clinically stable after an exacerbation, and must be strongly advised not to smoke near oxygen equipment due to fire risk.