Anaemia history taking

Question 1

Background of anaemia

Answer 1

low concentration of haemoglobin- <135g/l men, <115g/l women, blood test used in diagnosis: can be caused by

• insufficient intake of iron, b12 or folate
• sickle cell or thalassemia (genetic)
• excess haemoglobin loss through overt/ covert bleeding- cancer?

Question 2

History of presenting complaint

Answer 2

Introduction, consent and explanation- let them tell the natural history of their current problem (so what has brought you here today?)
How long have you felt this way? Gradual/ sudden/ anything bring it on
Pattern? e.g time of day
Anthing make it better or worse?
Any associated symptoms?
Other general questions- appetite? any changes in weight (especially loss), how are you sleeping? general mood? headaches? fever symptoms?

Question 3

History of presenting complaint continued

Answer 3

Heart and lungs can be affected by anaemia so ask about

• Shortness of breath
• Shortness of breath while lying down
• Waking up short of breath during night
• Chest pain
• Palpitations
• Fainting
• Ankle swelling

Question 4

What causes to consider in HPC?

Answer 4

Ask especially about diet- what do they normally eat, are they vegan/ vegetarian etc
GI- vomiting blood/ coffee ground material, indigestion/heartburn/reflux- passing blood in stool/ very dark or black motions?
GU- heavy or frequent menstrual bleeding/ pregnancy/ blood in urine/ dark urine?
Resp- chronic cough/ chest infections/ sputum/ coughing up blood

Also- nosebleeds, bleeding gums and easy bruising

Question 5

Past medical history

Answer 5

How is your general health? any medical conditions/ operations?
I’m going to run through a few conditions to make sure we don’t miss anything
- recent injuries, previous blood transfusions, high blood pressure, stroke, diabetes, peptic ulcer disease, previous anaemia

Question 6

Drug history

Answer 6

Do you take any medication? any new medication?
- prescribed medications
- over the counter medications (aspirin/ NSAIDS especially- GI bleeding)
- Herbal medication
- side effects/ allergies? what type of reaction?
Any illicit drug use

Question 7

Family history

Answer 7

Any inherited blood disorders- do any medical conditions run in your family? which members/ age of onset?

Question 8

Social history

Answer 8

do you smoke? if so what? how many per day/ have you ever smoked?
Alcohol- how many units pw?
occupation? previous job?
how have the symptoms impacted your life?

Question 9

To finish the consultation

Answer 9

Review of systems? Resp, GI, GU, MSK, nervous

summarise findings back to patient- ensure nothing has been missed