What questions should I ask a patient presenting with shortness of breath (dyspnea) and hemoptysis to gather a thorough history of present illness (HPI)?

History of Present Illness for Shortness of Breath and Hemoptysis

Begin by characterizing the hemoptysis volume and duration, as this immediately stratifies risk and determines whether the patient requires emergent intervention or can be managed as an outpatient. 1

Hemoptysis Characterization

• Quantify the blood volume: Ask specifically about teaspoons, tablespoons, or cups of blood to distinguish scant (<5 mL), mild (5-240 mL), or massive (>240 mL) hemoptysis, as this determines immediate management and disposition 1, 2, 3
• Duration and frequency: Determine when it started, whether it's persistent or intermittent, and if there have been prior episodes 3
• Blood characteristics: Ask if it's blood-streaked sputum, frank blood, or clots, and whether it's bright red (suggesting active bleeding) or darker 3
• Confirm true hemoptysis: Differentiate from hematemesis (vomiting blood from GI tract) or epistaxis (nosebleed draining posteriorly) by asking about nausea, vomiting, or nasal symptoms 3

Dyspnea Assessment

• Onset and progression: Determine if shortness of breath is acute (hours to days) or chronic (weeks to months), as chronic progressive dyspnea suggests underlying lung disease like malignancy or pulmonary fibrosis 4, 5, 6
• Severity grading: Ask about dyspnea at rest, with minimal exertion (dressing, walking across room), walking on level ground, walking up inclines, or climbing stairs 4
• Positional changes: Inquire about orthopnea (shortness of breath lying flat) or paroxysmal nocturnal dyspnea, which suggest heart failure or pleural effusion 4
• Duration: Specifically ask "For how long have you felt short of breath?" 4

Associated Respiratory Symptoms

• Cough characteristics: Ask about productive cough with phlegm, timing (morning, lying down), and whether cough preceded the hemoptysis 4
• Wheezing or stridor: Determine if there are audible breathing sounds suggesting airway obstruction 4
• Chest pain: Ask specifically about pleuritic pain (sharp, worse with deep breathing), which suggests pleural involvement or pulmonary embolism 4
• Recurrent pneumonia: Inquire about recent or recurrent infections in the same lung location, as this raises concern for endobronchial obstruction from malignancy 4, 3

Cardiovascular Symptoms

• Syncope or near-syncope: Ask "Have you ever passed out or felt you were about to pass out?" as this suggests pulmonary hypertension or massive pulmonary embolism 4, 5
• Chest pain with exertion: Determine if there's anginal chest pain or tightness during physical activity 4
• Palpitations: Ask about sensation of irregular or rapid heartbeat 4
• Leg swelling: Inquire about bilateral lower extremity edema, which suggests heart failure or cor pulmonale 4

Risk Factors for Malignancy and Serious Disease

• Smoking history: Document pack-years (age started, duration, packs per day), as smoking with hemoptysis raises concern for bronchogenic carcinoma even with normal chest X-ray 4, 3
• Age over 40: This is a high-risk feature requiring more aggressive workup 1
• Weight loss: Quantify unintentional weight loss over recent months, as significant weight loss suggests malignancy or chronic infection 4, 7
• Tuberculosis exposure: Ask about TB contacts, prior TB infection, immigration from endemic areas, or immunosuppression 4, 3

Infection and Inflammatory Symptoms

• Fever and chills: Recent or current fever suggests infectious etiology like pneumonia or tuberculosis 3, 6
• Recent antibiotic use: Ask about recent treatment for pneumonia or bronchitis, as persistent symptoms despite antibiotics warrant further investigation 5, 7
• Sputum production: Characterize color (purulent suggests infection) and quantity 4

Medication and Anticoagulation History

• Anticoagulants or antiplatelet agents: Document use of warfarin, DOACs, aspirin, or NSAIDs, as these increase bleeding risk 2
• Current medications: Specifically ask about medications for breathing problems, heart trouble, blood pressure, or seizures 4

Past Medical History Relevant to Hemoptysis

• Prior lung disease: Ask about asthma, COPD, bronchiectasis, pulmonary fibrosis, or prior lung cancer 4, 2
• Cardiovascular disease: Document history of heart failure, pulmonary hypertension, or mitral stenosis 4
• Prior chest trauma or surgery: Ask about rib fractures, chest injuries, or thoracic procedures 4
• Autoimmune conditions: Inquire about vasculitis, lupus, or other connective tissue diseases that can cause pulmonary hemorrhage 3

Common Pitfall to Avoid

Do not dismiss small amounts of blood-streaked sputum in patients with smoking history and COPD as simply "bronchitis," as hemoptysis may be the presenting symptom of lung cancer even with normal or nonlocalizing chest radiograph. 4 Persistent hemoptysis, even in scant amounts, requires investigation for endobronchial tumor 4.