History and Physical Examination Template for Shortness of Breath
A comprehensive HPI for shortness of breath should include specific details about the symptom characteristics, associated factors, and impact on the patient's life to guide accurate diagnosis and management.
Core Components of Dyspnea HPI
1. Symptom Characteristics
- Onset: Sudden vs. gradual development
- Duration: Acute (<1 month) vs. chronic (>1 month)
- Pattern: Constant, intermittent, progressive, or episodic
- Severity: Using Modified Medical Research Council (mMRC) Dyspnea Scale 1
- Grade 0: Only breathless with strenuous exercise
- Grade 1: Breathless when hurrying or walking up slight hill
- Grade 2: Walks slower than people of same age due to breathlessness
- Grade 3: Stops for breath after walking ~100m or after few minutes
- Grade 4: Too breathless to leave house or breathless when dressing
2. Aggravating and Alleviating Factors
- Triggers: Exercise, position changes, environmental factors (allergens, pollution)
- Relief measures: Rest, medications, position changes (specify which positions help)
- Diurnal variation: Worse at night, early morning, or with activity
3. Associated Symptoms
- Respiratory: Cough (productive/non-productive), wheezing, chest pain, hemoptysis
- Cardiac: Palpitations, chest pain/pressure, orthopnea, paroxysmal nocturnal dyspnea
- Constitutional: Fever, weight loss, fatigue, night sweats
- Other: Leg swelling, syncope/presyncope, anxiety
4. Impact on Daily Function
- Exercise tolerance: Distance walked before stopping, number of stairs climbed
- Activities of daily living: Impact on self-care, household activities
- Sleep: Ability to lie flat, need for multiple pillows, nocturnal awakenings
- Work/social activities: Limitations in occupational or recreational activities
Risk Factors and Medical History
1. Pulmonary Risk Factors
- Smoking history: Pack-years, current/former/never, quit date
- Occupational exposures: Dusts, chemicals, asbestos
- Environmental exposures: Air pollution, allergens
2. Relevant Medical History
- Pulmonary conditions: COPD, asthma, interstitial lung disease, prior pulmonary embolism
- Cardiac conditions: Heart failure, coronary artery disease, arrhythmias
- Other conditions: Anemia, obesity, neuromuscular disorders, anxiety disorders
3. Medication History
- Current medications: Particularly inhalers, cardiac medications
- Recent medication changes
- Response to previous treatments for dyspnea
Physical Examination Focus Areas
1. Vital Signs
- Respiratory rate: Normal vs. tachypnea
- Oxygen saturation: At rest and with exertion
- Heart rate and blood pressure
- Temperature: To assess for infection
2. Respiratory Examination
- Work of breathing: Use of accessory muscles, intercostal retractions
- Breath sounds: Wheezing, crackles, decreased breath sounds, stridor
- Percussion: Dullness (effusion, consolidation) vs. hyperresonance (COPD)
3. Cardiac Examination
- Heart sounds: Murmurs, gallops (S3, S4), irregular rhythm
- Jugular venous pressure: Elevated in heart failure
- Peripheral edema: Location and severity
4. Other Systems
- Upper airway: Signs of obstruction or vocal cord dysfunction
- Extremities: Cyanosis, clubbing, edema
- Neurological: Muscle strength, evidence of neuromuscular disorders
Diagnostic Considerations
1. Initial Testing Based on Presentation
- Pulse oximetry: Rest and with exertion
- Spirometry/PFTs: For suspected obstructive or restrictive disease 1
- Chest imaging: Radiograph or CT based on clinical suspicion
- Laboratory studies: CBC, basic chemistry, BNP when appropriate
2. Advanced Testing When Indicated
- Arterial blood gas: For suspected respiratory failure or acid-base disturbance 1
- Echocardiography: For suspected cardiac etiology 1
- Exercise testing: For unexplained dyspnea or to assess functional capacity 1
Documentation Example
"68-year-old female presents with gradually worsening shortness of breath over 3 months, now with dyspnea after walking half a block (mMRC Grade 3). Symptoms worse with exertion and when lying flat, requiring 3 pillows to sleep. Reports occasional wheezing and productive cough with clear sputum in the mornings. Denies chest pain, fever, or hemoptysis. History of hypertension and 30 pack-year smoking history (quit 5 years ago). Previously active, now limited in grocery shopping and household chores due to breathlessness. Albuterol inhaler provides temporary relief. Physical exam notable for respiratory rate of 22, oxygen saturation 92% on room air, bilateral lower lobe crackles, and trace bilateral ankle edema."
By systematically documenting these elements, clinicians can better differentiate between cardiac, pulmonary, and other causes of dyspnea, leading to more accurate diagnosis and appropriate management.