What is an example of a History of Presenting Illness (HPI) in a Subjective, Objective, Assessment, and Plan (SOAP) note for a patient with a respiratory infection?

Example of a History of Presenting Illness (HPI) in a SOAP Note for Respiratory Infection

The History of Presenting Illness (HPI) section should comprehensively document the onset, duration, and progression of respiratory symptoms, focusing on clinically relevant features that impact patient outcomes. 1

Essential Components of HPI for Respiratory Infection

Chief Complaint and Duration

• "Patient presents with a 5-day history of productive cough with yellow-green sputum, progressively worsening shortness of breath, and intermittent fever up to 101.8°F."

Symptom Characteristics

• Cough: Document onset, duration, character (productive/non-productive), timing (day/night/constant), and aggravating/relieving factors
• Sputum: Note color (clear, yellow, green, rust-colored, blood-tinged), consistency, and volume
• Dyspnea: Document severity, onset, progression, and impact on daily activities
• Fever: Record pattern, highest temperature, associated chills or sweats

Associated Symptoms

• "Patient also reports nasal congestion, sore throat (7/10 severity), pleuritic chest pain that worsens with deep breathing, generalized fatigue, and decreased appetite for the past 3 days."
• Document presence/absence of headache, myalgia, rhinorrhea, wheezing, hemoptysis

Chronology and Progression

• "Symptoms began with mild sore throat and nasal congestion 7 days ago, progressing to cough on day 3, with increasing sputum production and development of shortness of breath over the past 48 hours."

Attempted Treatments

• "Patient has been taking over-the-counter acetaminophen for fever with temporary relief, and honey with lemon for cough with minimal improvement."

Risk Factors and Exposures

• "Patient reports exposure to a family member with similar symptoms 1 week prior to onset."
• Document recent travel, occupational exposures, smoking history, and vaccination status

Impact on Function

• "Symptoms have caused patient to miss 3 days of work and report difficulty sleeping due to cough and shortness of breath."

Sample Complete HPI for Respiratory Infection

Mr. Smith is a 45-year-old male with a history of mild asthma who presents with a 5-day history of productive cough, shortness of breath, and fever. Symptoms began 7 days ago with sore throat and nasal congestion, which he initially attributed to seasonal allergies. Three days later, he developed a cough that has become increasingly productive of yellow-green sputum (approximately 1-2 tablespoons per episode). Over the past 48 hours, he has experienced progressive shortness of breath, particularly with exertion such as climbing stairs. He reports intermittent fever with highest recorded temperature of 101.8°F, associated with chills and night sweats.

The patient describes moderate pleuritic chest pain (5/10) that worsens with deep breathing or coughing. He denies hemoptysis but reports his sputum has become thicker and darker over the past 2 days. His cough is worse at night and disrupts his sleep. He has experienced decreased appetite, generalized fatigue, and myalgia. He has been taking acetaminophen 1000mg every 6 hours for fever with temporary relief and honey with lemon for cough with minimal benefit.

The patient reports exposure to his son who had similar symptoms approximately 1 week before his symptom onset. He received his influenza vaccination 3 months ago but has not received a pneumococcal vaccine. His asthma has been well-controlled on as-needed albuterol, which he has been using more frequently (3-4 times daily) since symptom onset with partial relief of his shortness of breath. He has missed 3 days of work due to these symptoms and reports his productivity and quality of life have been significantly impacted.

Common Pitfalls to Avoid

• Failing to document the duration and progression of symptoms, which can lead to misdiagnosis 1
• Not specifying sputum characteristics, which provide valuable diagnostic information 2
• Omitting assessment of symptom impact on daily activities and quality of life
• Neglecting to document attempted treatments and their effectiveness
• Overlooking relevant exposures and risk factors that might guide diagnosis and management 2

By thoroughly documenting these elements in the HPI section of a SOAP note, clinicians can better assess the nature and severity of respiratory infections, guide appropriate diagnostic testing, and develop effective management plans.