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."