Review of Systems Flashcards
General
Current weight and any recent change; weakness, fatigue; fever; energy level.
Endocrine
History of thyroid disease; history of high blood sugar; recent intolerance
to heat or cold; excessive thirst, hunger, or volume of urine output.
Hemotologic
History of anemia; easy bruising or difficulty controlling bleeding; history of blood transfusions including dates, reactions to blood products; history of blood clots or anticoagulation.
Psychiatric
History of treatment for psychiatric or emotional problems; nervousness; anxiety; undue sadness; sleep disturbance; death wishes or suicidal thoughts.
Skin
Recent changes in texture or appearance of hair, skin, or nails; new rashes, lumps, sores; history of treatment for skin condition.
Head
Any headache, head injury
Eyes
Recent change in vision; blurring of vision; double vision; red or painful eyes;
history of glaucoma or cataracts; most recent eye examination and results.
Ears
Recent change in hearing; pain in or drainage from ears; ringing in the ears; dizziness with or without changes in head position.
Nose and Sinuses
Increase in frequency of colds or nasal drainage; nosebleeds; history of sinus infections.
Mouth, throat, teeth:
Sores of tongue or mouth; dental problems and dental care history; bleeding of gums; hoarseness or voice change.
Neck
Stiffness or injury; new lumps or swelling.
Breasts
Tenderness; lumps; nipple discharge; history of self-examination; last physician
examination and/or mammogram; any prior aspiration or biopsy.
Cardiac/blood vessels
History of high blood pressure; heart disease; heart murmur; palpitations; chest pain or pressure; shortness of breath on exertion or while lying down; ankle swelling; history of electrocardiogram, chest x-ray, or other diagnostic tests; pain in legs with walking (how far); sensitivity or color change in fingers or toes with cold temperatures; varicose veins or history of phlebitis.
Respiratory
History of asthma, bronchitis, pneumonia, pleurisy, tuberculosis; new cough, sputum, coughing blood, wheezing or shortness of breath.
Gastrointestinal
Difficulty swallowing, change in appetite; nausea, vomiting; diarrhea; abdominal pain, vomiting blood, or blood in stool; constipation or recent change in bowel habits or appearance of stool; history of jaundice, liver or gallbladder problems; indigestion or new food intolerance.
Urinary
Change in frequency of urination, volume of urine, or nature of stream; burning on urination; blood in urine; hesitancy; urgency; incontinence; history of urinary
infections or stones; nocturia.
Male Genitoreproductive
History of hernia; venereal diseases; sores on penis; pain in testicle; frequency of testicular self-examination; sexual orientation, function, satisfaction, or concerns if not raised and covered adequately in earlier portions of the history.
Female Genitoreproductive General
Menstrual history, including age of menarche, cycle
length, pain with menses, change in duration, amount, or frequency of menses (may be omitted in the postmenopausal woman).
Female Genitoreproductive Older Women
For the older woman, history of age and any difficulty with menopause such as hot flashes, irregular bleeding; history of hormone therapy, postmenopausal vaginal bleeding.
Female Genitoreproductive All Postmenarcheal
For all postmenarcheal women, history of venereal disease, vaginal discharge, painful sexual intercourse, vulvar itching, or unexpected vaginal bleeding. Sexual orientation, activity, satisfaction, and concerns if they have not been discussed during other portions of the history. If not obtained earlier, the history of pregnancy and delivery, birth control method(s), and concerns about reproductive health may be asked at this time.
Musculoskeletal
Muscle weakness, pain, tenderness, or stiffness; pain or swelling in joints; history of arthritis, gout, or back pain.
Neurologic
History of seizures, blackouts; paralysis; numbness or tingling; trembling or weakness; difficulty speaking; memory loss or difficulty concentrating.
Sleep
Difficulty getting to sleep, staying asleep; poor quality/non-restorative sleep; fall asleep or become severely drowsy while driving, reading, watching television, attending meetings or lectures; snore heavily or stop breathing in sleep, awakening with gasp, short of breath; morning headache.
