General Constitutional

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Trace DC5-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Subjective — ask

  • Fever, chills, or sweats — pattern and timing; night sweats.
  • Fatigue or malaise — onset, severity, and impact on specific function.
  • Unintentional weight change — amount and timeframe; appetite and intake change (detail in Nutrition).
  • New or worsening overall “feeling unwell” and any associated localizing symptoms.
  • Functional change — what the patient can no longer do, or now needs help with, since the prior visit.
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