Anemia History

  • 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
  • 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

 


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