Weight Loss History

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• CC:
  • What is the current weight and height? (calculate BMI)
  • How much did you lose?
  • Over how long?
  • Was it intentional?
  • Onset: first time? Sudden\gradual? Continuous\intermittent?
  • Severity: interfering w\ ADL?

Associated sx:

• Constitutional: fever, loss of appetite, night sweats, chills?

• GI: abdominal pain, N\V, change in bowel habits (diarrhea)?

• Decreasedoralintake: difficulty swallowing, painful mouth ulcers, early satiety?

• Eating****disorder: fear of gaining wt, feel fat, binge eating (episodes of uncontrollable eating), self-induced vomiting?

• Depression: low mood, loss of interest?

• Hyperthyroid: heat intolerance, palpitations, tremor, menstrual changes?

• Cardiac****failure: SOB, LL swelling?

• Respiratory: chest pain, cough, hemoptysis?

• Liver: jaundice?

• DM: polyuria, polyphagia, polydipsia?

• Urinary: dysuria, hematuria?

• Diet:

  • Recent change in diet habits?
  • How many meal\snacks per day?
  • What type of food do you usually eat?
  • Do you exercise?

• PMHx:

  • Diseases:
    • Chronic ds (HTN, DM, DLP)
    • Anemia, Hyperthyroidism
    • Infections, malignancy
  • Medications: laxatives, diuretics, OTC, herbals
  • 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

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Clinical Skills, History