Haematologic system

{Haematologic system} [+] yes, present, positive [-] no, absent, negative [~] equivocal [\] not applicable, not performed [?] unknown, unsure, unavailable { } annotation, comment PRESENTING COMPLAINTS OR ISSUES Reasons for visit: [-] new problem/issue [-] review/follow-up Presenting symptoms: [-] abnormal blood loss/bleeding [-] epistaxis [-] gums/oral cavity [-] PV [-] PR [-] symptoms of anaemia (eg, fatigue, dyspnoea) [-] easy bruising [-] pallor [-] lymph node enlargement [-] bone pain [-] glossitis (sore tongue) [-] paraesthesia [-] rashes/petechiae [-] frequent infections History of presenting complaint: Onset: Location: Severity (/10): Quality: Timing: Context: Aggravated by: Relieved by: Management to date: - Diagnostic investigation results: [+] [~] [-] [?] PAST MEDICAL HISTORY Relevant past medical history: [-] blood loss, including surgery [-] blood transfusions [-] gastric surgery [-] terminal ilium resection [-] B12 deficiency [-] iron deficiency [-] gastrointestinal malabsorption [-] rheumatoid arthritis [-] renal failure MEDICATIONS Medication history: [-] anticonvulsants [-] NSAIDs [-] anticoagulants/platelet inhibitors [-] immune suppressants SOCIAL HISTORY Diet: [-] vegan diet [-] alcohol use Occupational history/environmental exposures: [-] Lead [-] other heavy metals [-] benzene [-] ionising radiation FAMILY HISTORY Relevant family history: [-] pernicious anaemia [-] bleeding disorders [-] thrombotic disorders [-] haemolytic anaemia [-] thalassaemia [-] sickle cell anaemia or trait [-] other blood disorder PHYSICAL EXAMINATION Relevant examination findings: [-] pallor [-] lymphadenopathy [-] splenomegaly ASSESSMENT Clinical summary: [+] [~] [-] Diagnosis/es: 1. 2. Differential diagnosis: - MANAGEMENT PLAN Procedures performed: - Diagnostic investigations requested: - Referrals: - patient information and advice: - Medication: - FOLLOW-UP Outstanding issues: - Next appointment: - [dqref.com 260131]

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