Respiratory exam post pic

Cough, Chest Pain and Fever – OSCE Case

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A 34-year-old man is referred to the medical assessment unit with a coughchest pain and a fever. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:


Presenting complaint

“My chest really hurts. I’ve had this horrible cough and feel really feverish”

History of presenting complaint

Chest pain

Where is the pain?

It feels like it’s at the bottom of my ribs on the left”

When did the chest pain start?

It started about 2 weeks ago, I thought it was because I’ve been coughing so much but it also hurts when I breathe in

Can you describe the pain?

It’s quite a sharp pain when I cough or breathe in deeply

Does the pain spread anywhere else?


Has the pain worsened?

I think so, it didn’t use to hurt when I breathed in but now it does

Does anything make it better?

Not really, but I try to take shallow breaths to avoid it

Does anything make it worse?

Breathing deeply or coughing

How would you rate the pain on a scale of 0 – 10?

It’s probably around a 7/10


When did the cough start?

The cough started about 3 weeks ago while I was in India visiting family, since I got it last week it’s been getting worse”

Is the cough constant or does it come and go?

It’s pretty constant but has been getting worse at night when I go to bed”

Is there anything that triggers the cough or anything that makes the cough better?

The cough is always there but it gets worse when I lie down and gets slightly better when I’m upright”

Do you bring up any sputum when you cough or is it dry/tickly?

At first I wasn’t bringing anything up but over the last week I’ve been bringing more and more mucus”

What colour is the mucus you’re bringing up?

It started clear but now it’s green

Have you ever coughed up any blood?

Maybe? Yesterday the mucus was dark red, but that only happened once”

For more information, see the Geeky Medics guide to cough history taking.

Shortness of breath

When did you start getting short of breath?

“Since the cough started, I’ve been getting short of breath but over the last week it’s gotten worse”

Is there anything that makes the shortness of breath worse?

“When I lie down it gets really bad, I’ve had to start using more pillows to go to bed”

Other symptoms

Have you had a wheeze?


Have you had any tiredness?

“Yes absolutely, I’m not sleeping as well and I’ve started having really feverish sleep”

Have you had a fever or night sweats?

“Both, I feel like I go hot and cold a lot, and recently I’ve been waking up drenched in sweat”

Have you had any weight loss?

“I think I’m looking thinner which is quite worrying because I’ve only been feeling ill for a few weeks!”

Have you had any change in taste or smell?


Have you had contact with anyone else with similar symptoms?

Not that I know of, but I met a lot of family in India who I don’t know very well

Have you had any recent foreign travel?

Yes, I was in India visiting family a few weeks ago, and I was there for 2 weeks

For more information, see the Geeky Medics guide to respiratory history taking.

Other parts of the history

Past medical and surgical history

  • Do you have any medical problems?

I was diagnosed with HIV 3 years ago, but nothing else

Medication history/allergies

  • Do you take any regular medication?
  • Do you have any allergies?

I’m on antiretrovirals for HIV but forgot to take them while I was in India. I don’t have any allergies

Family history

  • Do any medical problems run in the family?

“Not that I know of”

Social history

  • Do you live with anyone?
  • Do you work currently?
  • Are you up to date with vaccinations?
  • Have you been vaccinated for tuberculosis (TB)?
  • Do you smoke?
  • Do you drink alcohol?
  • Do you use recreational drugs?

“I live alone and work in IT. I think I’m up to date with my normal vaccinations but I’m not sure about TB, I don’t think I’ve had a vaccine for that. I don’t drink or smoke and I’ve never taken drugs”

Clinical examination

Respiratory examination

Examination findings


  • No scar
  • No chest wall deformity


  • Trachea central
  • Mildly reduced expansion on the left side


  • Crackles on the left side
  • Reduced air entry on the lower left side
  • Decreased vocal fremitus on lower left side


  • Stony dull percussion on the lower left side


This patient is presenting with pleuritic chest pain and shortness of breath, making a chest X-ray the most appropriate initial investigation.

Chest X-ray

The patient’s chest X-Ray is shown below.

The patient's chest X-ray
Figure 1. The patient’s chest X-ray.1

Dense opacity pleural effusion in the left lung.


Pleural fluid aspiration should be performed and analysed with the following:

  • Appearance: purulent (infection), bloody (malignancy, PE, trauma)
  • Biochemistry: protein, LDH, glucose
  • Microbiology: Gram stain, culture
  • Cytology

Light’s criteria distinguishes between exudative and transudative pleural effusions. The fluid is exudate if one or more of the following criteria are met:

  • Pleural fluid protein divided by serum protein is >0.5
  • Pleural fluid LDH divided by serum LDH is >0.6
  • Pleural fluid LDH is >⅔ the upper limit of the laboratory normal value for serum LDH



After further investigations, the patient is diagnosed with tuberculosis.

Rifampicin, isoniazid, pyrazinamide, and ethambutol are the antibiotics used to treat tuberculosis.





Dr Jess Speller


  1. Clinical Cases. Left-sided pleural effusion. License: [CC-BY-SA].
  2. S. Crane and C. Wearmouth for RCEM Learning. Pleural Effusion. Published in 2011. Available from: [LINK].
  3. R. Light et al. Pleural Effusions: The Diagnostic Separation of Transudates and Exudates. Published in 1972. Available from: [LINK].
  4. Patient Info. Tuberculosis. Published in 2019. Available from [LINK].
  5. NICE. Tuberculosis. Published in 2016. Available from [LINK].


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