- CC: most likely will present as bruising or bleeding from any site;
- Site: where?
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
- Timing: day\night? How frequent?
- Character: color?
- Aggravating\relieving factors: what triggered it (trauma)? How did it stop?
- Severity: estimate the amount? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, wt loss, loss of appetite, night sweats, chills, lymphadenopathy?
- Blood loss: Easy bruising? Bleeding from gums or nose? Vomiting or coughing up blood? Blood in stool, urine? Menorrhagia? Joint pain\swelling?
- Hemolysis: jaundice, dark urine, pale stool, gallstones, abdominal pain?
- Anemia: headache, palpitations, SOB, fatigue?
- PMHx:
- Previous bleeding: after tooth extraction, surgery?
- Diseases:
- Chronic ds (HTN, DM, DLP)
- Hematological, renal, liver ds
- Infections, malignancy
- Medications: NSAIDs, steroids, aspirin, anticoagulants, antibiotics
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Allergies
- Previous bleeding: after tooth extraction, surgery?
- 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 (consumption of green vegetables), exercise