Breathlessness OSCE station: a history that finds the cause

27 October 2026

In short: In a breathlessness station, start with how quickly it came on, because sudden and gradual breathlessness point to different causes. Then ask the questions that separate the common groups: airways and lung disease, heart failure and pulmonary embolism. Cover smoking, occupation and clot risk factors, grade how much the breathlessness limits the patient, and summarise a prioritised differential.

Key points

Speed of onset is the first sorting question: minutes, days or months.
Ask about cough, sputum, wheeze, chest pain, haemoptysis, orthopnoea, waking at night and ankle swelling.
Smoking history and occupation matter for chronic lung disease.
Clot risk factors include recent immobility or surgery, previous DVT or PE, and cancer.
Grade the breathlessness, for example with the MRC dyspnoea scale.

Where this sits in the content map

Breathlessness is a named presentation in Domain 5 of the GMC's MLA content map. Domain 6 lists the conditions you would consider, including asthma, chronic obstructive pulmonary disease (COPD), heart failure, pulmonary embolism, pneumonia, pneumothorax, interstitial lung disease, lung cancer and anaemia. The GMC asks candidates to build a broad differential and to remember that patients may describe their symptoms in their own words. "I can't get my breath", "my chest feels tight" and "I get tired walking" may all mean the same thing.

Start with onset and timing

After introducing yourself and gaining consent, ask an open question, then pin down the timeline:

When did it start, and how quickly? Sudden onset over minutes raises different possibilities from a slow decline over months.
Is it constant, or does it come and go?
What brings it on? Exertion, lying flat, cold air, exercise, allergens, time of day.
How far can you walk now, compared with before?

Questions that separate the causes

Work through the associated symptoms in whatever order the patient leads you:

Cough and sputum: how long, how much, what colour.
Wheeze
Chest pain: pleuritic, central, or none.
Haemoptysis
Orthopnoea and waking at night breathless
Ankle swelling
Fever, weight loss and fatigue
Palpitations

NICE guidance on COPD (NG115) suggests suspecting COPD in people over 35 with a risk factor, generally smoking or a history of smoking, who have one or more of: exertional breathlessness, chronic cough, regular sputum production, frequent winter "bronchitis" or wheeze. It also suggests asking about weight loss, reduced exercise tolerance, waking at night with breathlessness, ankle swelling, fatigue, occupational hazards, chest pain and haemoptysis. NICE notes that the last two are uncommon in COPD and raise the possibility of another diagnosis.

Risk factors and background

Smoking: current or past, and how much.
Occupation: dust, chemicals or other exposures at work.
Clot risk: NICE's two-level PE Wells score includes signs of DVT, heart rate over 100, immobilisation for more than 3 days or surgery in the previous 4 weeks, previous DVT or PE, haemoptysis and malignancy. In a history station, ask about the ones you can: leg swelling or pain, recent immobility or surgery, previous clots and cancer.
Cardiac history: previous heart attack, high blood pressure, known heart failure.
Asthma and allergy history, including childhood asthma and family history.
Medications and allergies, and whether inhalers are being used and how.

Grade the breathlessness

NICE recommends the Medical Research Council (MRC) dyspnoea scale to grade breathlessness in COPD by the level of exertion that brings it on. Grade 1 is not troubled by breathlessness except on strenuous exercise; grade 2 is short of breath when hurrying or walking up a slight hill. Even outside COPD, asking how far the patient can walk, and whether they can manage stairs or daily tasks, shows the examiner you are measuring impact, not just presence.

Social history and impact

Ask who is at home, how they manage day to day, and what they are worried about. The GMC's content map asks for contextual factors such as employment, housing and lifestyle in the history. A patient who has stopped going out because of breathlessness is telling you something important.

Summarise and say what you would do next

Give a short summary and a prioritised differential. If asked about next steps, base them on the guideline for the likely cause. For example:

Suspected heart failure: NICE (NG106) recommends a history, clinical examination and tests, including measuring NT-proBNP.
Suspected PE: NICE (NG158) uses the two-level PE Wells score to decide the next test.
Suspected COPD: NICE (NG115) recommends post-bronchodilator spirometry to confirm the diagnosis.

If the patient is acutely unwell, escalate. Say so clearly.

How MedExamHelper fits

MedExamHelper stations open with a prebrief showing the setting, patient, complaint and your task, but not the diagnosis. The AI patient is instructed never to volunteer more than the question asks, so the questions you don't ask stay unanswered, just as they would in an exam.

Common questions

What should I ask first in a breathlessness history? After an open question, find out when it started and how quickly. Onset over minutes, days or months narrows the differential quickly.

Which symptoms point away from COPD? NICE notes that chest pain and haemoptysis are uncommon in COPD and raise the possibility of another diagnosis.

How do I grade breathlessness? NICE recommends the MRC dyspnoea scale for COPD, which grades breathlessness by the level of exertion that brings it on.

Should I ask about clot risk factors in every breathlessness station? It's worth covering them briefly. Pulmonary embolism is a serious cause, and the risk factors are quick to ask about.