Review of Systems Flashcards
what is the purpose of review of systems?
- check the past and present health of each system
- check for any data “omitted” in the current illness section
- determine health promotion practices
health history components
- biographical data
- reason for seeking care,
- current health/history of current illness,
- past health,
- family history,
- review of systems (subjective), functional assessment
- ADLs
what is the order of the ROS exam?
approximately head to toe
what should you avoid during ROS?
avoid medical terms
which 5 systems are covered in detail for ROS?
neurological, musculoskeletal, cardiac and peripheral vascular, respiratory, abdominal
general overall health
- how do you feel overall?
- any recent changes to overall health status?
skin, hair, nails
eczem, moles, pruritus, bruising
health promotion: sunscreen used? amount of sun exposure? skin care for diabetic feet
- nails: change in shape, colour, brittleness?
head
headaches, head injury, dizziness, health promotion: use of helmets? vision and difficulty? blurred or double vision? pain?
health promotion: eye exams? can you afford exams and glasses?
ears
earaches, infections? discharge? hearing loss? hearing aids?
health promotion: protection from environmental noise?
nose and sinuses
colds, discharge, hay fever, smell
mouth and throat
bleeding gums, toothache, altered taste, dysphagia,
health promotion: dental care? can you afford it?
neck
limitations of motion, pain, swelling
breasts and axilla
surgery, lumps, nipple discharge, tenderness,
health promotion: mammograms? BSE?
respiratory
history of lung disease (asthma, pneumonia, wheezing)? how much activity produces shortness of breath? any cough or sputum?
health promotion: ask about date of chest x-ray
cardiovascular
any pain? palpitations? SOB? amount of exertion that trigger SOB? hyper tension, dyspnea, anemia, coronary artery disease,
health promotion: has the pt ever had an EKG o other test?