Bleeding History

  • 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
  • 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

 


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