History of Present Illness Template for Shortness of Breath
A comprehensive HPI for shortness of breath should include the onset, duration, severity, associated symptoms, aggravating/relieving factors, and relevant medical history to guide accurate diagnosis and management.
Essential Elements to Include
Characteristics of Dyspnea
- Onset and timing: When did the shortness of breath begin? Was it sudden or gradual?
- Duration: How long has the symptom been present? Is it constant or intermittent?
- Severity: Rate on a scale (1-10) or describe impact on daily activities
- Progression: Is it getting better, worse, or staying the same?
- Positional changes: Does it worsen when lying flat (orthopnea)? How many pillows are needed to sleep comfortably?
- Exertion relationship: Does it occur at rest or with activity? What level of activity triggers symptoms?
Associated Symptoms
- Chest pain: Character, location, radiation, severity, duration
- Cough: Productive or non-productive, sputum characteristics (color, amount, consistency)
- Wheezing or stridor: Timing and triggers
- Hemoptysis: Amount, frequency, duration
- Fever or chills: Onset, duration, maximum temperature
- Edema: Location, timing, severity
- Palpitations: Character, frequency, associated symptoms
Aggravating and Relieving Factors
- Triggers: Exercise, allergens, cold air, lying flat, stress
- Relief measures: Rest, sitting upright, medications, inhalers, oxygen
- Response to interventions: What has been tried and what was the effect?
Relevant Medical History
- Cardiac history: Prior heart failure, coronary disease, arrhythmias
- Pulmonary history: Asthma, COPD, prior pneumonia, tuberculosis
- Risk factors: Smoking history (pack-years), occupational exposures, travel history
- Medications: Current medications, recent changes, compliance
Functional Impact
- Activity limitations: How has this affected daily activities?
- Sleep disturbances: Nocturnal awakenings due to breathlessness
- Work/school impact: Missed days, limitations in performance
Sample Template
"[Patient name] is a [age]-year-old [gender] with [relevant past medical history] who presents with shortness of breath that began [timing of onset]. The dyspnea is described as [patient's description] and is rated as [severity scale]. The shortness of breath [is/is not] present at rest and [is/is not] exacerbated by [specific activities]. The patient [can/cannot] lie flat and requires [number] pillows to sleep comfortably. Associated symptoms include [list relevant symptoms]. The dyspnea is worsened by [aggravating factors] and improved with [relieving factors]. The patient [has/has not] tried [interventions] with [response]. The shortness of breath has affected the patient's life by [functional impact]. Relevant medical history includes [pertinent history]."
Common Pitfalls to Avoid
- Failing to distinguish between cardiac and pulmonary causes
- Not documenting the impact on daily activities and quality of life
- Overlooking important associated symptoms that may suggest specific diagnoses
- Neglecting to document response to previous treatments or interventions
- Missing information about sleep-related breathing problems (orthopnea, paroxysmal nocturnal dyspnea)
By systematically documenting these elements, clinicians can develop a comprehensive picture of the patient's dyspnea that will guide appropriate diagnostic testing and management 1.