Identification Data
• Name:
• Age:
• Sex:
• Education status:
• Occupation:
• Address:
• Religion:
Chief Complaints
• Mention complaints in chronological order with duration.
Example:
• Cough since ___ days/months
• Sputum production since ___ days/months
• Breathlessness since ___ days/months
• Fever since ___ days/months
• Chest pain since ___ days/months
• Hemoptysis since ___ days/months
• Wheezing since ___ days/months
• Weight loss/loss of appetite since ___ days/months
• Swelling of feet since ___ days/months
• Hoarseness of voice since ___ days/months
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History of Presenting Illness (HOPI)
Describe each symptom in detail and in chronological sequence.
1. Cough
Duration
Acute (<3 weeks)
Subacute (3–8 weeks)
Chronic (>8 weeks)
Onset
Sudden
Insidious
Nature
Dry/non-productive
Productive
Timing
Continuous
Intermittent
Worse at night
Worse in early morning
Seasonal variation
Progression
Improving
Static
Progressive
Aggravating factors
Exercise
Dust exposure
Cold weather
Lying down
Smoke exposure
Allergens
Relieving factors
Medications
Steam inhalation
Sitting up
Rest
Associated symptoms
Fever
Breathlessness
Wheeze
Chest pain
Hemoptysis
Weight loss
Nasal symptoms
Heartburn
Etiological clues
Early morning cough with scanty sputum → Chronic bronchitis
Nocturnal cough → Asthma, heart failure
Dry irritating cough → Interstitial lung disease, ACE inhibitor use
Paroxysmal cough → Pertussis, asthma
Postural cough → Bronchiectasis, lung abscess
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2. Sputum Production
Duration
Acute
Chronic
Quantity
Scanty
Moderate
Copious (>100 mL/day)
Colour
Mucoid (white)
Mucopurulent (yellow)
Purulent
Rust coloured
Pink frothy
Black
Blood stained
Consistency
Thin
Thick
Tenacious
Odour
Odourless
Foul smelling
Timing
More in morning
Postural variation
Layering
Single layer
Three-layered sputum
Special points
Copious purulent sputum → Bronchiectasis
Foul-smelling sputum → Anaerobic infection/lung abscess
Rust coloured sputum → Pneumococcal pneumonia
Pink frothy sputum → Pulmonary edema
Black sputum → Coal workers’ pneumoconiosis
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3. Breathlessness (Dyspnea)
Duration and onset
Sudden
Gradual
Progression
Progressive
Episodic
Severity
Assess using:
Modified Medical Research Council (mMRC) Scale
Grade 0:
Breathless only with strenuous exercise.
Grade 1:
Short of breath when hurrying or walking uphill.
Grade 2:
Walks slower than people of same age or stops while walking.
Grade 3:
Stops after walking about 100 metres.
Grade 4:
Too breathless to leave house or breathless while dressing.
Character
Continuous
Episodic
Timing
Daytime
Nocturnal
Seasonal
Aggravating factors
Exertion
Dust
Cold weather
Allergens
Infection
Relieving factors
Rest
Sitting upright
Medications
Orthopnea
Number of pillows used
Sudden onset after lying down
Paroxysmal Nocturnal Dyspnea
Episodes of awakening at night due to breathlessness
Associated symptoms
Wheezing
Chest pain
Fever
Cough
Pedal edema
Palpitations
Etiological clues
Episodic dyspnea with wheeze → Asthma
Progressive dyspnea with smoking history → COPD
Progressive dyspnea with dry cough → Interstitial lung disease
Sudden dyspnea → Pneumothorax, pulmonary embolism
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4. Chest Pain
Site
Central
Unilateral
Diffuse
Onset
Sudden
Gradual
Character
Sharp
Dull aching
Stabbing
Burning
Tightness
Severity
Pain score (0–10)
Radiation
Shoulder
Back
Neck
Arm
Timing and duration
Aggravating factors
Deep inspiration
Coughing
Movement
Exercise
Relieving factors
Rest
Analgesics
Sitting forward
Associated symptoms
Fever
Breathlessness
Cough
Hemoptysis
Etiological clues
Pleuritic pain → Pneumonia, pleurisy, pulmonary embolism
Sudden severe pleuritic pain → Pneumothorax
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5. Hemoptysis
Number of episodes
Amount
Streaking
Teaspoonful
Cupful
Massive (>500 mL in 24 hours)
Colour
Bright red
Dark red
Mixed with sputum
Character
Fresh blood
Clots
Preceded by coughing
Not related to cough
Associated symptoms
Fever
Weight loss
Breathlessness
Chest pain
Differentiate from:
Hematemesis
Nausea and vomiting
Coffee-ground appearance
Food particles
Acidic pH
Pseudohemoptysis
Bleeding from nose, mouth, or throat
Common causes
Tuberculosis
Bronchiectasis
Pneumonia
Lung malignancy
Pulmonary embolism
Mitral stenosis
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6. Wheezing
Sudden
Gradual
Duration and frequency
Pattern
Episodic
Persistent
Seasonal
Triggers
Dust
Smoke
Exercise
Cold air
Pollen
Drugs
Relieving factors
Inhalers
Associated symptoms
Breathlessness
Cough
Chest tightness
Suggestive of
Bronchial asthma
COPD
Cardiac asthma
Airway obstruction
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7. Fever
Duration
Acute
Chronic
Grade
Low grade
Moderate
High grade
Pattern
Continuous
Intermittent
Remittent
Associated features
Chills and rigors
Sweating
Weight loss
Cough
Sputum
Suggestive of
Pneumonia
Tuberculosis
Lung abscess
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8. Weight Loss and Loss of Appetite
Amount of weight lost
Associated symptoms
Fever
Night sweats
Hemoptysis
Cough
Suggestive of
Tuberculosis
Malignancy
Chronic lung disease
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9. Hoarseness of Voice
Progression
Associated symptoms
Cough
Weight loss
Neck swelling
Suggestive of
Recurrent laryngeal nerve involvement
Lung carcinoma
Mediastinal pathology
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10. Swelling of Feet
Progression
Bilateral/unilateral
Associated symptoms
Breathlessness
Abdominal distension
Suggestive of
Cor pulmonale
Congestive cardiac failure
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Constitutional Symptoms
Loss of appetite
Weight loss
Fatigue
Malaise
Fever
Night sweats
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History Suggestive of Tuberculosis
Chronic cough (>2 weeks)
Fever (especially evening rise)
Night sweats
Weight loss
Loss of appetite
Hemoptysis
Previous TB treatment
Contact with TB patient
Drug compliance if already on treatment
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History Suggestive of Bronchial Asthma
Episodic breathlessness
Wheezing
Chest tightness
Nocturnal symptoms
Seasonal variation
Trigger factors
Atopy
Family history
Previous hospital admissions/ICU admissions
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History Suggestive of COPD
Age >40 years
Chronic cough
Chronic sputum production
Progressive dyspnea
Smoking history
Occupational exposure
Previous exacerbations
Hospital admissions
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History Suggestive of Malignancy
Weight loss
Loss of appetite
Hemoptysis
Hoarseness
Persistent chest pain
Smoking history
Clubbing
Bone pain
Neurological symptoms
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Past History
Previous episodes of similar illness
Tuberculosis
Asthma
COPD
Pneumonia
Pleural effusion
Hospital admissions
ICU admissions
Previous surgeries
Blood transfusions
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Drug History
Bronchodilator use
Steroid therapy
Anti-tubercular therapy
Long-term oxygen therapy
Nebulization
ACE inhibitor use
Drug allergies
Compliance with medications
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Treatment History
Previous investigations
Previous diagnosis
Treatment received
Response to treatment
Hospitalizations
Mechanical ventilation
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Personal History
Appetite
Normal/reduced
Diet
Vegetarian/mixed
Sleep
Adequate/disturbed
Orthopnea
PND
Bowel habits
Normal/abnormal
Bladder habits
Normal/abnormal
Addictions
Smoking History
Smoker/non-smoker/ex-smoker
Type of smoking:
- Cigarettes
- Bidis
- Hookah
- E-cigarettes
Number per day
Duration in years
Pack years (in Cigarette smokers):
Pack years = (Cigarettes/day × Years smoked) ÷ 20
Alcohol history
Type
Quantity
Duration
Tobacco chewing
Quantity
Duration
Substance abuse
Type
Duration
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Occupational History
Occupation
Exposure to:
Dust
Silica
Asbestos
Coal dust
Cotton dust
Chemicals
Fumes
Bird exposure
Farming exposure
Use of protective equipment
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Environmental History
Biomass fuel exposure
Indoor air pollution
Passive smoking
Overcrowding
Recent travel
Exposure to pets/birds
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Allergy History
Dust allergy
Pollen allergy
Food allergy
Drug allergy
Animal exposure
Seasonal allergies
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Family History
Tuberculosis
Asthma
COPD
Allergy/atopy
Lung cancer
Interstitial lung disease
Genetic disorders
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Menstrual and Obstetric History (if applicable)
Pregnancy
Oral contraceptive use
Postpartum status
History suggestive of pulmonary embolism risk
Mr./Ms. ______, a __yr old Male/Female, resident of _______ and working as a ____, presented with complaints of ____________ for the past _____months/year.
The patient was apparently asymptomatic until ______ ago, when he/she developed cough, which was of gradual/sudden onset and progressive/non-progressive in nature. It was non-productive cough, OR productive cough with expectoration — continuous/intermittent, occurring predominantly during the day/night/early morning, with no significant diurnal variation/marked diurnal variation. Aggravated by dust exposure, cold, exercise, smoke, or lying down and was relieved by medications, steam inhalation, rest, or sitting upright.
- Early morning productive cough → Chronic bronchitis
- Nocturnal cough → Bronchial asthma / left heart failure
- Dry irritating cough → Interstitial lung disease, post-viral cough
- Postural cough → Bronchiectasis / lung abscess
- Paroxysmal cough → Asthma / pertussis
The sputum was Absent, OR present since ____.It was Scanty/moderate/copious in quantity; mucoid/mucopurulent/purulent in nature, white/yellow/green/rust/pink frothy/blood-stained/black in colour, odourless/foul-smelling.The sputum was expectorated Predominantly in the morning, and did/did not show postural variation.
- Copious purulent sputum → Bronchiectasis
- Foul-smelling sputum → Lung abscess, anaerobic infection
- Rust-coloured sputum → Pneumococcal pneumonia
- Pink frothy sputum → Pulmonary edema
- Black sputum → Coal workers' pneumoconiosis
The patient developed breathlessness, which was Sudden/gradual in onset, progressive/non-progressive; continuous or episodic with symptom-free intervals. Aggravated by exertion, dust, cold, smoke, or infections; relieved by rest, sitting upright, or bronchodilators. mMRC Grade ___. The patient did/did not have orthopnea, PND, nocturnal awakenings due to breathlessness.
- Episodic breathlessness with wheeze → Bronchial asthma
- Progressive dyspnea in smoker → COPD
- Progressive dyspnea with dry cough → Interstitial lung disease
- Sudden onset dyspnea → Pneumothorax, pulmonary embolism
The patient did/did not experience wheezing, since ___days. If present, it was episodic/persistent, seasonal/non-seasonal, triggered by dust, smoke, cold, exercise, or allergens and relieved by bronchodilators.The wheeze was Associated with breathlessness, chest tightness, and cough.
- Bronchial asthma
- COPD
- Airway obstruction
The patient did/did not complaint of chest pain since __ days. If present: location over ________, sudden/gradual in onset, sharp/dull/stabbing/burning in nature, severity _/10, continuous/intermittent, radiating to ________. Aggravated by deep inspiration, coughing, or movement and relieved by rest, analgesics, or sitting forward.
- Pleuritic chest pain → Pneumonia, pleurisy, pulmonary embolism
- Sudden severe pleuritic pain → Pneumothorax
The patient did/did not have hemoptysis since ___ days. If present, __ episodes/day, streaking/teaspoonful/cupful/massive amount, bright red/dark red in colous, mixed/not mixed with sputum, associated with cough.The Patient denied hematemesis, epistaxis, and gum bleeding.
- Tuberculosis
- Bronchiectasis
- Pneumonia
- Lung carcinoma
- Pulmonary embolism
- Mitral stenosis
The patient did/ did not have fever since ___ days. If present, low-grade/moderate/high-grade, continuous/intermittent/remittent, with/without chills, rigors, or sweating.
- Acute fever with cough and sputum → Pneumonia
- Evening rise of temperature with weight loss → Tuberculosis
- Fever with foul sputum → Lung abscess
Loss of appetite / weight loss / fatigue / malaise / night sweats — present/absent.
- Weight loss and anorexia → Malignancy, tuberculosis
- Night sweats → Tuberculosis, lymphoma
- Fatigue and malaise → Chronic respiratory illness
Hoarseness of Voice: Present/absent. If present: gradual/sudden onset, progressive/non-progressive, associated with cough, weight loss, or neck swelling.
- Recurrent laryngeal nerve palsy
- Bronchogenic carcinoma
- Mediastinal pathology
Pedal Edema: Present/absent since ___ days. If present, bilateral/unilateral, involving Right/left leg, progressive/non-progressive, associated with abdominal distension or breathlessness.
- Cor pulmonale
- Congestive cardiac failure
The patient gave/no Past history of bronchial asthma, TB, COPD, pneumonia, pleural effusion, bronchiectasis, COVID-19, hospitalization, ICU/ventilation, surgeries, or blood transfusions
Patient was/not on bronchodilators, steroids, ATT, LTOT, nebulization, ACE inhibitors, or indigenous medications.No history of any Drug allergy.
His/her Appetite is normal/reduced.He/she consumes Vegetarian/mixed diet. Sleep is adequate/disturbed. Bowel and bladder habits are normal.
Smoking: The patient is Non-smoker/ex-smoker/current smoker.He/she smokes __cigarettes/bidis per day for __ years, giving a smoking index of ____ Or Pack year of ____ pack years. Alcohol and tobacco chewing history present/absent.
Occupational/Environmental:No history/History of Exposure to silica, asbestos, coal dust, cotton dust, chemical fumes, farming, or birds.
Allergy:No history/history of Dust, pollen, food, drug, or seasonal allergy / atopy.
Family History:No history of TB, asthma, COPD, atopy, lung cancer, ILD, or similar complaints in family.
Mr./Ms. ______, a _-year-old ________, presented with mild cough for ___ days, with no history of sputum production, breathlessness, wheezing, chest pain, hemoptysis, fever, constitutional symptoms, smoking, occupational exposure, allergies, or significant past and family history, suggestive of an uncomplicated upper respiratory tract infection.
Mr./Ms. ______, a _-year-old chronic smoker, presented with cough with mucoid expectoration for _ months, intermittent low-grade fever with evening rise of temperature, loss of appetite, weight loss, night sweats, and occasional hemoptysis for ___ duration, with history of contact with a tuberculosis patient, suggestive of pulmonary tuberculosis.
Mr./Ms. ______, a ___-year-old individual with personal/family history of atopy, presented with recurrent episodes of breathlessness, wheezing, chest tightness, and nocturnal cough precipitated by dust and cold exposure and relieved by bronchodilator therapy, suggestive of bronchial asthma.
Mr./Ms. ______, a _-year-old chronic smoker with _ pack-years, presented with chronic productive cough and progressive exertional breathlessness for ___ years with recurrent exacerbations, suggestive of chronic obstructive pulmonary disease (COPD).
