Comprehensive History of Present Illness (HPI) Template for Shortness of Breath
A comprehensive HPI for shortness of breath should include onset, duration, severity, associated symptoms, aggravating/relieving factors, and relevant medical history to guide accurate diagnosis and management. 1
Core Elements of Shortness of Breath HPI
Characterization of Dyspnea
Onset and timing:
- When did the shortness of breath begin? (sudden vs. gradual)
- Is it constant or intermittent?
- Time of day when symptoms are worse (morning, night, during sleep)
- Relationship to activity, position, or time of day
Severity:
- Rate on scale of 1-10
- Impact on daily activities (using mMRC dyspnea scale) 2
- Progression since onset (improving, worsening, stable)
Quality:
- How does the patient describe the sensation? (air hunger, chest tightness, inability to take deep breath)
- Is there wheezing, stridor, or other audible sounds?
Aggravating and Alleviating Factors
- What makes breathing worse? (exertion, lying flat, environmental triggers)
- What makes breathing better? (rest, sitting upright, medications)
- Response to previous treatments or interventions (medications, inhalers, oxygen) 1
Associated Symptoms
Respiratory:
- Cough (productive vs. non-productive)
- Sputum (amount, color, consistency, blood-tinged)
- Chest pain (location, quality, radiation, timing)
- Hemoptysis
- Wheezing or stridor
Cardiovascular:
- Palpitations
- Edema (location, timing, progression)
- Orthopnea (number of pillows needed)
- Paroxysmal nocturnal dyspnea
- Syncope or near-syncope
Constitutional:
- Fever or chills
- Weight changes
- Fatigue
- Night sweats
- Sleep disturbances related to breathing 1
Risk Factors and Medical History
Pulmonary History
- Asthma, COPD, bronchitis, emphysema
- Previous pneumonia, tuberculosis, pulmonary embolism
- Lung cancer or other respiratory conditions 2
- Prior pulmonary function testing results
- Previous chest imaging findings
Cardiovascular History
- Hypertension, coronary artery disease, heart failure
- Previous myocardial infarction, stroke, arrhythmias
- Heart valve disorders
- Peripheral vascular disease 1
Other Relevant History
- Smoking history (current/former, pack-years)
- Occupational exposures (asbestos, chemicals, dusts)
- Environmental exposures (allergens, pollution)
- Recent travel history
- Recent immobilization or surgery
- Family history of respiratory or cardiac disease 1
Medication Review
- Current medications (especially cardiac and respiratory)
- Recent medication changes
- Use of inhalers or nebulizers (frequency, technique)
- Over-the-counter medications
- Medication allergies or adverse reactions 3, 4
Impact Assessment
- Effect on sleep quality
- Limitations on daily activities
- Work/school performance impact
- Exercise tolerance (blocks walked, stairs climbed)
- Quality of life changes 1
Red Flags to Document
- Sudden onset severe dyspnea
- Dyspnea at rest
- Associated chest pain
- Syncope
- Hemoptysis
- Severe hypoxemia (SpO2 <94%)
- Respiratory distress signs (accessory muscle use, tripod positioning)
- Inability to speak in complete sentences 1
Documentation Example Format
"Patient is a [age]-year-old [gender] presenting with shortness of breath for [duration]. Onset was [sudden/gradual], and symptoms are [constant/intermittent/progressive]. Dyspnea is rated as [#/10] in severity and [is/is not] present at rest. Patient [can/cannot] speak in full sentences. Symptoms are worse with [activities/positions/times] and improved by [interventions]. Associated symptoms include [relevant symptoms]. Patient has [relevant past medical history] and [relevant risk factors]. Current medications include [list]. Impact on daily life includes [functional limitations]."
This comprehensive template ensures thorough documentation of all relevant aspects of shortness of breath, facilitating accurate diagnosis and appropriate management planning.