Review of Systems and Medical screening

Question 1

What are you checking for patients overall physical and mental well-being?

Answer 1

Physical - weight changes, fatigue/lethargy

Emotional - anxiety/hopelessness

Question 2

Nausea/vomiting what do you inquire?

Answer 2

is there a reason for nausea? Describe how it looks
Any unusual signs and symptoms?
Vomiting w/ or w/o nausea?
Taking OTC meds?

Question 3

Nausea/Vomiting Referral

Answer 3

Persistent vomiting - report to physician

Nausea with increased need meds or other signs

Question 4

What are some causes for N and V?

Answer 4

GI disorders
Infection
MI
Cancer - advanced
Migraines
Pregnancy 
Adverse Drug reactions

Question 5

What is significant temperature for fever?

Answer 5

99.5º or higher for > 2 weeks
102 = urgent referral
dont use temp as indicator of infection

Question 6

How do older patients portray fever?

Answer 6

fatigue, malaise, decreased thermoregulation

Question 7

What are some concerns with night sweats?

Answer 7

regular, interrupt sleep, have other sxs, weight loss

Can also occur with menopause, meds, room too warm

Question 8

What can cause fever/sweats/chills?

Answer 8

infections
metastatic cancers
rheumatic disorders
menopause

Question 9

What are Red flags of weight change

Answer 9

5-10% BW or decrease BW over 4-6 month period

unexplained

Question 10

What are referral exceptions to weight change? (pregnancy/CHF)

Answer 10

Pregnancy: >5lb wt gain in 1wk or >5lb loss in first trimester
CHF: >2-3lbs in a day

Question 11

What are causes of weight change?

Answer 11

Metastatic cancers (unexplained >10lbs over 6 months)
Depression
GI disorders
Infection
Anorexia nervosa 
Chronic pulmonary, cardiac or renal failure 
Rheumatic disorders
Endocrine/thyroid disorder

Question 12

What are the paresthesia concerns in a patient?

Answer 12

Bilateral, atypical pattern or UE/LE together, other neuro signs (vision, taste, smell, hearing
Saddle groin anesthesia
Disorders contributing: neurologic disorders, endocrine disorders, renal disease, adverse drug reactions

Question 13

What are the weakness concerns in a patient?

Answer 13

Concern if non-myotomal - nerve root
Cern if other neuro signs present (vision, taste, smell, hearing)
Urinary retention, increased frequency, overflow incontinence

Weakness w/ negative neuro exam = yellow flag

Question 14

What are the balance concerns in a patient?

Answer 14

Dizziness or lightheadedness - vestibular/vascular insufficiency
Possible disorders contributing - neurologic disorders, adverse drug reaction, MSK injury/disease

Question 15

What are the cautions to night pain?

Answer 15

Difficulty sleeping or falling asleep due to sxs, wakes at night due sxs and unable to easily fall back sleep, pain not to relieved by lying down, pain unchanged with position, food, frequency, duration

possibly due to infection, neoplasm, OA other inflammation

Question 16

What are the concerns of fatigue?

Answer 16

If interfering with function for more than 2-4 weeks. Esp if not related to above factors

Especially if not related to work or life stresses

Question 17

What are concerns of malaise?

Answer 17

Uneasiness or general discomfort

Often associated with fever

PT needs to inquire if not on medical screen form

Question 18

What are factors to consider with impaired mentation/cognition?

Answer 18

Based on observation - alert? oriented? Attention and thought process?
Difficult to asses - determine over time or discuss with family member
Possible disorders - infection (elderly), adverse drug reaction, neurologic disorder, drug alc abuse

YELLOW FLAG

Question 19

What 2 questions are used for screening depression

Answer 19

During the past month have u been feeling down to depressed or hopeless

During the past month have you experienced little interest or pleasure in doin things?

Would you like help?