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Weight Loss History


  • 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?
  • Eatingdisorder: 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?
  • Cardiacfailure: 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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Published by Nadanotes

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Clinical Skills, History


over 2 years ago

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