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20 Cards in this Set
- Front
- Back
REVIEW OF SYSTEMS
General |
Weight (Average, Recent change, Minimum, Maximum)
Weakness Fatigue Fever Sweats Chills Anorexia Insomnia (can’t sleep) Hypersomnolence (sleep all the time) |
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REVIEW OF SYSTEMS
Skin |
Lesions
Lumps Growths Sores Moles Change in color/pigmentation, eruptions/rashes Pruritus (itching) Dryness Excessive sweating Easy bruising Changes in nails/hair Birthmarks Change in temperature |
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REVIEW OF SYSTEMS
HEENT Head |
Headache
Head injury Change in size Deformity Dizziness Syncope (lightheaded) Vertigo (spinning) |
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REVIEW OF SYSTEMS
HEENT Eyes |
Vision, use of glasses/contacts
Pain Diplopia (double vision) Glaucoma Cataracts Itching Spots Photophobia Color blindness Night blindness Blurry vision Ptosis (droopy eyelids) Halos (rings around lights) Scotomata (blind spot) Redness Tearing Discharge (color,consistency) Use of eye drops Last eye exam |
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REVIEW OF SYSTEMS
HEENT Ears |
Pain
Hearing loss Deafness Discharge (color, consistency, bloody) Infections Tinnitus (ringing) Vertigo Pruritus (itching) Use of hearing aid |
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REVIEW OF SYSTEMS
HEENT Nose/Sinuses |
Runny nose
Stuffiness Discharge (color, consistency) Pruritus (itching) Epistaxis (nose bleeds) Pain over sinuses Hay fever Frequent colds |
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REVIEW OF SYSTEMS
HEENT Mouth/Throat |
Sores
Lesions Condition of teeth and gums Sore throats Hoarseness Dental caries Loss of teeth Dentures Change in taste Bad taste Malodorous breath Bleeding Dry mouth Last dental exam |
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REVIEW OF SYSTEMS
Neck |
Pain
Swelling Limits in range of motion or stiffness Lumps Swellings “Swollen glands” |
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REVIEW OF SYSTEMS
Breast |
Lumps
Pain Swelling Nipple discharge Use of self-exam Last mammogram |
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REVIEW OF SYSTEMS
Respiratory |
Cough
Sputum (color, quantity) Hemoptysis (blood from lungs/bronchus) Wheezing Asthma Emphysema Bronchitis Pneumonia Tuberculosis Pleurisy Shortness of breath Last chest x-ray |
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REVIEW OF SYSTEMS
CV |
History of heart disease
Chest pain (exertional/nonexertional, associated symptoms) Orthopnea (discomfort breathing by lying flat) PND (Paroxysmal Nocturnal Dyspena) Dyspnea on exertion (shortness of breath) Edema Cyanosis (blue skin) Palpitations (irregular heartbeats) Loss of consciousness Hypertension Heart murmur Claudication (limping/calf muscle weakness) Thrombophlebitis (inflamed veins) Varicosities (dilated veins) Raynaud’s Phenomenon (bilateral cyanosis of digits) Rheumatic Fever |
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REVIEW OF SYSTEMS
GI |
Change in appetite
Abdominal pain Difficulty/pain with swallowing Heartburn Indigestion Bloating Belching Nausea Vomiting Hematemesis (vomiting blood) Jaundice Food intolerance Frequency of bowel movements Change in bowel habits (frequency, consistency, caliber, constipation, diarrhea) Melena (dark colored stools) Hematochezia (bloody stools) Clay-colored stools Mucus (passing mucus) Excessive belching or passing of gas Incontinence (inability to prevent discharge) Hemorrhoids Rectal itching/burning Rectal discharge/pain Laxative use Hepatitis Gall bladder disease |
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REVIEW OF SYSTEMS
GU (urinary) |
Frequency of urination
Dysuria (difficulty/pain urination) Hematuria (blood in urine) Change in color of urine Polyuria (excess urine) Nocturia (pee a lot at night) Oliguria (not much urine) Anuria (no urine) Flank/suprapubic pain Retention (can’t fully void) Urgency (desire to void) Hesitancy (involuntary delay) Incontinence Change in force of stream Dribbling Passage of air/stone Enuresis (leakage of urine) Past infections |
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REVIEW OF SYSTEMS
GU (female) |
Menstrual history (onset, cycle, duration, amount of flow, change in cycle)
LMP Amenorrhea (loss of cycle) Menorrhagia (excessive menses) Metrorrhagia (irregular menses) Associated pain or PMS symptoms Contraceptive history Previous pregnancies (deliveries, abortions, complications, outcomes) Exposure to DES (diethylstilbestrol) Age at menopause Menopause symptoms Postmenopausal bleeding Vaginal discharge Pruritus Abscess Sores Lesions Infections STD’s PID (Pelvic Inflammatory Disease) RPR status (Rapid Plasma Reagin test – syphilis) HIV status Previous PAPs Premenstrual symptoms Problem with intercourse (pain, satisfaction, libido) Sexual orientation Number of partners Menopausal symptoms (hot flashes, mood swings, changes in vaginal lubrication) |
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REVIEW OF SYSTEMS
GU (male) |
Hernias
Penile discharge Sores Testicular pain or lumps STD’s RPR/HIV status Sexual orientation Number of partners Problems with intercourse (impotence, satisfaction, limbido) Contraceptive use |
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REVIEW OF SYSTEMS
Endocrine |
Goiter
Exophthalmos (eyeballs protrude) Hot/cold intolerance Constipation/diarrhea Tremor Excessive sweating Palpitations Change in voice Skin changes Hair distribution Secondary sex characteristics Changes in body contour or weight Changes in hat/glove/shoe size Polyuria (increase urine) Polydipsia (increase thirst) Polyphagia (increase eating) Striae (stretch marks) Acne Pigmentation Infertility Diabetes Thyroid disorders |
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REVIEW OF SYSTEMS
MS |
Pain in an extremity
Join pain Swelling Redness Stiffness Deformity Limited range of motion Warmth Crepitation (note location of each joint involved) (cracking joints) History of arthritis Muscle pain Gout Backache Neck pain Trauma |
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REVIEW OF SYSTEMS
Neurologic |
Syncope
Dizziness Seizures Vertigo Ataxia (uncoordinated movements) Limp Frequent falls Tremor Involuntary movement Weakness Loss of muscle mass Paralysis Incoordination Clumsiness Pain Numbness Paresthesia (abnormal sensation, burning, tickling) Hyperesthesia (abnormal acuteness to touch) Dysarthria (speech change) Changing in handwriting Incontinence (bowel or urine) |
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REVIEW OF SYSTEMS
Hematologic |
Anemia
Easy bruising Past transfusions and any reactions to them IV drug use Enlarged lymph nodes Hemoglobinopathies (abnormal hemoglobins e.g., sickle cell anemia) |
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REVIEW OF SYSTEMS
Psychiatric |
Nervousness
Anxiety Mood swings Depression Change in memory Crying spells Early awakening Problems sleeping Loss of energy Change in libido Suicidal thoughts Change in appetite Binge eating Purging Excessive exercising Hallucinations Paranoia Disturbing/unusual thoughts Panic episodes |