History

 taking  in  Hematology  

  1. Name     6. Resident    
Personal   2. Age     7. Occupation    
history   3. Sex   8. Special  habit  
4. Marital  status   • Smoking  
5. Age  of  last  child   • Alcohol    
  • Drugs  
Chief   Complain  +  Onset  
complain  
  1. Analysis  of  complain  à  Onset,  course  duration  
    • Sudden:  minute  à  hours  
  Onset   • Acute:  days  à  months  
  • Gradual  à  weeks  to  months  
  • Insidious  à  unrecognizable    
    • Progressive  
  Course   • Regressive    
  • Stationary    
 
Duration   By  patients  on  words    
 
2. Ask  for  symptoms  of  same  system  
 
    • Headache  
  Anemia   • Blurring  of  vision    
  • Tinnitus    
  • SOB    
  • Palpitation,  chest  pain  
  • Weakness,  muscle  fatigue  
    • Bleed  from  orifice:  hemoptysis,  hematemesis,  melena,  epistaxis,  bleed  from  gum  
  Bleeding   • Bleed  subcutaneous:  petichea,  purpura,  ecchymosis  
  • Bleed  in  deep  organ:  bleed  from  closed    cavity,  hematoma  
    Leucopenia   Severe  Leukocytosis  
Present   Leucopenia   • Exposed  to  infections     • Blurring  of  vision    
history   Leukocytosis   • Recurrent  infections     • Headache  
• Chest  infection     • Coagulopathy    
• Oral  ulcer    
  • Lymph  node  
Swelling   • Organ:  liver,  spleen    
• Mass    
Transfusion     • When  (only  in  duration  of  start  chief  complain,  if  before,  consider  as  past  hx)  
• What  type  
• How  many  pack  
  • Night  fever   • Loss  of  weight  
B  symptoms   • Night  sweats   • Bone  ache  
3. Ask  for  other  system  
  • Palpitation,  dyspnea,  fatigue  
  • Angina    
CVS   • Intermittent  claudication    
• CHF  
• AMI  
Chest     •  
  • Faintness,  giddiness,  drowsiness  
CNS   • Paresthesis,  paraplegia,  hemiplegia,  hemiparesis,    
• Decrease  muscle  strength,    numbness  
  • Anorexia,  dysphagia  
  • Nausea  &  vomiting    
GIT   • Constipation,  flatulence    
• Piles,  gastritis  
  • Menstrual  changes:  amenorrhea,  menorrhagia  
  • Amount,  days  of  menstruation    
Genito  –urinary   • Contraceptive  used:  IUD  
• Loss  of  libido  and  priaprism  in  men    
• Colour,  smell,  amount  of  urine  and  stool  

4. Patient  story  
• When  he  seek  for  primary  medical  advice?  
• Is  there  any  investigation  done?  
• Is  there  any  drugs  prescribed?  
• Does  his  condition  improved?  Or  not  improve  with  medication?  
• Mention  the  positive  associated  symptoms  then  mention  the  negative  symptoms  
• Mention  the  positive  associated  symptoms  of  other  system  and  the  negative  associated.    
5. DM,  HTN  
• Yes  or  no  for  DM  and  HTN   • Drugs  taken    
• Since  when     • Controlled  or  uncontrolled  
Past  history   • Similar  condition     • Surgery  done    
• Hospitalization  history    include  Ix,  treatment     • Travel  abroad  
Family   • Similar  condition    
history   • Consanguity