Example of a History of Presenting Illness for a Respiratory Infection
A comprehensive history of presenting illness for a respiratory infection should include the onset, duration, and progression of symptoms, focusing particularly on cough, shortness of breath, sputum production, and fever, as these are the most clinically relevant symptoms impacting patient outcomes. 1
Core Elements to Include
Chief Complaint and Timeline
- Duration and onset of symptoms (e.g., "Patient presents with a 7-day history of persistent fever, dry cough, and progressive shortness of breath") 2
- Progression pattern (e.g., worsening despite previous treatments, stable, or improving)
Respiratory Symptoms (in order of clinical significance)
Shortness of breath (dyspnea)
- Severity and triggers (at rest, with exertion)
- Impact on daily activities
- Progression (sudden vs. gradual worsening)
- This symptom has the greatest impact on mortality and morbidity 1
Cough
Sputum characteristics
- Color (clear, white, yellow, green, blood-tinged)
- Consistency (thin, thick, purulent)
- Volume
- Changes in characteristics over time 3
Systemic Symptoms
- Fever (document highest temperature and duration)
- Chills or rigors
- Fatigue or weakness
- Myalgia (muscle pain)
- Headache
- Sore throat
- Nasal congestion or rhinorrhea 3, 4
Associated Symptoms
- Gastrointestinal symptoms (nausea, vomiting, diarrhea)
- Chest pain or discomfort (pleuritic vs. non-pleuritic)
- Wheezing or audible stridor
- Voice changes
- Ear pain or fullness 3, 5
Risk Factors and Context
Medical History
- Underlying respiratory conditions (asthma, COPD, bronchiectasis)
- Immunocompromised status
- Smoking history (current, former, pack-years)
- Vaping or e-cigarette use 2
- Recent hospitalizations or healthcare visits
- Previous similar episodes 6
Epidemiological Information
- Recent travel
- Occupational exposures
- Known sick contacts
- Vaccination status (influenza, pneumococcal, COVID-19)
- Recent antibiotic use 5
Previous Interventions
- Prior treatments attempted (antibiotics, steroids, inhalers)
- Response to previous treatments 2
Sample HPI Format
"Mr. X is a [age]-year-old [gender] with [relevant past medical history] who presents with a [duration]-day history of [primary symptoms]. The illness began with [initial symptoms] and has [progressed/improved/remained stable] over time. The patient reports [severity and character of cough], [presence and description of sputum], and [degree of shortness of breath]. Associated symptoms include [fever/maximum temperature], [systemic symptoms], and [other relevant symptoms]. The patient [has/has not] experienced [hemoptysis, chest pain, wheezing].
Prior to presentation, the patient [tried home remedies/visited urgent care/took medications] with [response to treatment]. The patient [has/has not] had similar episodes in the past. Relevant risk factors include [smoking status, exposures, vaccination status, recent illnesses or contacts]."
Common Pitfalls to Avoid
Failing to document the duration and progression of symptoms, which helps distinguish between acute bronchitis, pneumonia, or exacerbation of chronic conditions 3
Not specifying the character of cough and sputum, which can guide diagnostic considerations 1
Overlooking systemic symptoms that might indicate severity or specific etiologies 5
Missing important epidemiological information that could suggest specific pathogens 7
Neglecting to document previous treatments and their effectiveness 2
By including these elements in a structured manner, the history of presenting illness will provide a comprehensive clinical picture that guides appropriate diagnostic testing and management decisions for respiratory infections.