From the Guidelines
A comprehensive history of present illness (HPI) template for shortness of breath should include onset, duration, severity, quality, aggravating factors, alleviating factors, associated symptoms, and temporal patterns, as well as relevant context and impact on daily activities, as outlined in the most recent guidelines 1. The template should document the following key components:
- Onset: when symptoms began and whether sudden or gradual
- Duration: how long symptoms have persisted
- Severity: using a scale of 1-10 or descriptive terms
- Quality: how the patient describes the sensation
- Aggravating factors: what makes breathing worse, such as exertion, lying flat, or environmental triggers
- Alleviating factors: what improves symptoms, including positions or medications
- Associated symptoms: cough, chest pain, fever, wheezing, leg swelling, palpitations
- Temporal patterns: whether symptoms are constant or intermittent, worse at certain times The template should also include relevant context, such as:
- Recent illness
- Travel
- Medication changes
- Similar previous episodes For proper clinical assessment, the template should also document:
- Impact on daily activities
- Exercise tolerance: how far the patient can walk before becoming short of breath
- Orthopnea: number of pillows needed to sleep comfortably
- Paroxysmal nocturnal dyspnea: waking up gasping for air
- Any home oxygen use with settings This detailed information helps distinguish between cardiac, pulmonary, or other etiologies of dyspnea, guiding appropriate diagnostic testing and management decisions, as supported by recent guidelines 1. In particular, the template should consider the patient's social circumstances and quality of life, as well as their smoking history and previous admissions, as outlined in earlier guidelines 1. However, the most recent and highest-quality study 1 should take precedence in guiding the development of the HPI template.
From the Research
History of Present Illness Template for Shortness of Breath
The following components should be included in a comprehensive history of present illness template for a patient presenting with shortness of breath:
- Onset and duration: When did the shortness of breath start and how long has it been present? 2
- Severity: How severe is the shortness of breath, and has it been worsening over time?
- Triggers: Are there any triggers that worsen or improve the shortness of breath, such as exercise, position, or environmental factors?
- Associated symptoms: Are there any associated symptoms, such as chest pain, cough, wheezing, or fatigue?
- Past medical history: Does the patient have a history of respiratory or cardiac disease, such as chronic obstructive pulmonary disease (COPD), asthma, or heart failure?
- Medications: Is the patient taking any medications that may be contributing to the shortness of breath, such as beta-blockers or sedatives?
- Oxygen therapy: Has the patient received oxygen therapy in the past, and if so, what was the response?
Respiratory Distress Evaluation
When evaluating a patient with shortness of breath, it is essential to consider the following:
- Oxygen saturation: What is the patient's oxygen saturation level, and is it being titrated to an appropriate level (e.g., 94-96% for most acutely ill medical patients and 88-92% in patients with acute COPD exacerbation)? 2
- Bronchospastic disease: Is the patient experiencing bronchospasm, and if so, has albuterol been administered? 2
- Systemic steroids: Has the patient been prescribed systemic steroids, which may be beneficial in patients with asthma or COPD? 2
- Non-invasive positive pressure ventilation (NIPPV): Is NIPPV being considered, which has been shown to be safe and effective in treating respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions? 2