Haematologic System

#Haematologic System

S: Subjective

Presenting Complaint:
(-) abnormal blood loss/bleeding
  (-) epistaxis
  (-) gums/opral cavity
  (-) PV
  (-) PR 
  (-) other -> 
(-) symptoms of anaemia (eg, fatigue, dyspnoea)
(-) easy bruising
(-) pallor
(-) lymph node enlargement
(-) bone pain
(-) glossitis (sore tongue)
(-) paraesthesia
(-) rashes/petechiae
(-) other/s ->

Symptom development:
- Onset: 
- Variation: 
- Aggravating factors: 
- Relieving factors:

Treatment History:
(-) anticonvulsants
(-) NSAIDs
(-) anticoagulants/platelet inhibitors
(-) immune suppressants

Past Medical History:
(-) blood loss, including surgery
(-) blood transfusions
(-) gastric surgery
(-) terminal ilium resection
(-) B12 deficiency
(-) iron deficiency
(-) gastrointestinal malabsorption
(-) rheumatoid arthritis
(-) renal failure

Social History:
(-) vegan diet
(-) alcohol use

Occupational History/Environmental Exposures:
(-) Lead
(-) other heavy metals
(-) benzene
(-) ionising radiation

Family History:
(-) pernicious anaemia
(-) bleeding disorders
(-) thrombotic disorders
(-) haemolytic anaemia
(-) thalassaemia
(-) sickle cell anaemia or trait
(-) other blood disorder ->

O: Objective

Examination:
(-) pallor
(-) lymphadenopathy
(-) splenomegaly

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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