- CC: most likely will present as fatigue;
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
- Timing: day\night? How frequent?
- Aggravating\relieving factors: activity, certain foods?
- Severity: 1-10 scale? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, wt loss, loss of appetite, night sweats, chills, lymphadenopathy?
- Anemia: headache, palpitations, dizziness, fatigue?
- Blood loss: Easy bruising? Bleeding from gums, nose? Vomiting or coughing up blood? Blood in stool, urine? Menorrhagia?
- Hemolysis: jaundice, dark urine, pale stool, gallstones, abdominal pain?
- Sickle cells: strokes, SOB, chest pain, bone pains, leg ulcers?
- Neurological: numbness\tingling, unsteady gait, confusion, visual problems?
- Nutrition: specific diet, avoids certain foods, craving non-nutritional materials (sand, ice)?
- DDx:
- Hypothyroid: constipation, cold intolerance, wt gain, hair loss?
- Heart failure: orthopnea, PND, LL swelling?
- Autoimmune: joint pain\swelling?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM, DLP)
- Hematological, renal ds
- Infections, malignancy
- Medications: NSAIDs, steroids, aspirin, anticoagulants, antibiotics, antimalarial, supplements
- Surgery (splenectomy), hospitalization (ICU admissions), trauma
- Blood transfusions, IV drug use, tattoos
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx, contact with sick pts?
- Diet, exercise