History of Present Illness for a Patient with Progressive Shortness of Breath
The initial evaluation of a patient with progressive shortness of breath should include a thorough cardiopulmonary assessment with appropriate diagnostic testing to determine the underlying etiology, as this symptom can represent significant cardiac, pulmonary, or multisystem disease requiring prompt intervention. 1
Key Elements for History of Present Illness
Symptom Characteristics
- Onset: When the shortness of breath began (sudden vs. gradual)
- Duration: How long symptoms have been present
- Progression: Whether symptoms are worsening, improving, or stable
- Exacerbating factors: Activities that worsen symptoms (exertion, lying flat)
- Alleviating factors: What improves symptoms (rest, sitting upright, medications)
- Severity: Impact on daily activities and quality of life
Associated Symptoms
- Chest pain or discomfort (suggesting cardiac etiology)
- Cough and sputum production (color, amount, consistency)
- Wheezing or audible breathing sounds
- Orthopnea or paroxysmal nocturnal dyspnea (suggesting heart failure)
- Lower extremity edema (suggesting heart failure or venous insufficiency)
- Fever, chills, or night sweats (suggesting infection)
- Weight changes (gain suggesting fluid retention; loss suggesting malignancy)
Contextual Factors
- Exercise tolerance: Quantify distance able to walk, stairs able to climb
- Impact on activities of daily living
- Recent travel or exposures
- Occupational history and potential exposures
Example History of Present Illness
Mr. Smith is a 65-year-old male who presents with a 3-month history of progressive shortness of breath. Initially, he noticed dyspnea only with moderate exertion such as climbing stairs or walking uphill, but over the past month, his symptoms have worsened to the point where he becomes short of breath after walking less than half a block on level ground. He reports associated bilateral lower extremity swelling that worsens throughout the day and improves somewhat overnight. He describes two-pillow orthopnea and waking up gasping for air approximately twice weekly. The patient denies chest pain but reports occasional palpitations with exertion. He has a chronic productive cough with clear sputum that has not changed in character. He reports a 10-pound weight gain over the past month despite no change in diet. His symptoms have been minimally responsive to the furosemide prescribed by his primary care physician two weeks ago. He denies fever, hemoptysis, or recent travel. His exercise tolerance has declined from being able to walk his dog for 30 minutes daily to now being unable to complete household chores without resting.
Differential Diagnosis Considerations
Cardiac Causes
- Heart failure (HFrEF or HFpEF) 2
- Valvular heart disease (especially mitral stenosis) 2
- Coronary artery disease
- Arrhythmias
Pulmonary Causes
- COPD exacerbation 2
- Asthma or exercise-induced bronchoconstriction 2
- Interstitial lung disease 2
- Pulmonary embolism
- Pulmonary hypertension
Other Causes
- Deconditioning
- Anemia
- Obesity
- Neuromuscular disorders
- Psychogenic dyspnea
Important Diagnostic Considerations
- Oxygen saturation assessment at rest and with exertion 2
- Cardiopulmonary exercise testing for patients with unclear etiology 1
- Echocardiography for suspected cardiac causes 2
- Pulmonary function testing for suspected respiratory causes 2
- Chest imaging (radiograph or CT) to evaluate for structural abnormalities
Remember that patients over 50 years with a long smoking history and chronic breathlessness on minor exertion should be treated as having suspected COPD until proven otherwise 2. Additionally, patients with valvular heart disease may present with progressive dyspnea as their primary symptom 2.