10.Review of Systems
Transcript of 10.Review of Systems
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SYSTEMATIC PROBLEM ASSESSMENT&
SUBJECTIVE DATA
“Review of Systems”(ROS)
J. Carley, MSN, MA, RN, CNEFall, 2009
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Example of Electronic Health Record (EHR)
Review of Systems Screen
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For each Symptom
OnsetDurationSeverityAlleviating FactorsAggravating Factors
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Helpful questions by system…………….
Skin – Integumentary SystemAny changes in color?Any pain or enlargement?Any itching or rashes?History of scarring or diseases?Sores that will not heal?Allergies to environmental allergens or food?Any new medications?
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Helpful questions by systemHead and NeckAny headaches?Dizziness?Syncope?Head injuries?Loss or change in consciousness?Thyroid problemsSwollen glands?Pain or stiffness of neckAny problems swallowing?
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Eyes, Ears, Nose, Throat – EENTVisual acuity problems? Changes?Last eye exam?Pain ? Where?Hearing loss?Discharge or drainage?Vertigo?Tinnitus?Sense of Smell?
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Eyes, Ears, Nose, Throat – EENTFrequent colds?Epistaxis?Postnasal drainage?Allergies?Recurrence of symptoms?Change in voice?Sore throat?Bleeding or Swelling of the gums?
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Eyes, Ears, Nose, Throat – EENTTooth abscesses or extractions?Swelling?Ulcers in mouth?Disturbance of taste?Last dental exam?
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Respiratory SystemLast chest x-ray?Respiratory allergies?Smoker? Tobacco or others – how much?Dyspnea? When?Pain with breathing?Orthopnea?
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Respiratory SystemAny cough?Sputum production?Hemoptysis?Wheezing?History of asthma, bronchitis,emphysema?
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Respiratory SystemLabored respirations?Frequent colds?Exposure to environmental hazards?TB risk?
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CardiovascularAny chest pain?Any dizziness?Any syncope?Palpitations?Dyspnea?
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CardiovascularHypertension?Familial risks?Smoker?Previous cardiac problems?Last EKG or cardiac tests?Edema? Where?
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CardiovascularVaricosities = varicose veins?Peripheral neuropathies?History of DVT?Swelling of feet, legs, handsPressure, pain or heaviness in arms, jaw, or chest
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CardiovascularLeg pain or cramps?Bleeding problems?Anemias?SOB with exertion?
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Breast & ChestPain/tenderness?Swelling?Discharge?New assymmetry?Last mammogram?Lumps?
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NeurologicalLoss of consciousness?Speech difficulty?Change in processing information?Swallowing difficulty?Confusion?
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Neurological
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NeurologicalWeakness?New Falls?Dropping items – weak grip?Change in balance, gait?
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NeurologicalBlurred vision?Numbness or tingling of extremities?Changes in sensory perception?
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GastrointestinalDyspepsia?Diarrhea?Constipation?Nausea or vomitting?Allergies/ food intolerances?Abdominal pain?
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GastrointestinalBloating?Excess flatus?Belching?Change in color of stools?Change in consistency of stools?Pain with eating or defecating?
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GenitourinaryHistory of kidney or bladder disease?Urinary frequency?Burning?Nocturia?Changes in urine color?Clarity or odor of urine?
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GenitourinaryPain?Excessive thirst?Swelling of legs, hands, eyelids?Dietary intake of calcium?Chills or fever?inability to urinate?
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GenitourinaryHesitancy of urination?Incontinence?
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Genitourinary – ReproductiveFemale history of pregnancy G: P: A:Onset of menses?Last menstrual cycle?Onset of menopause?Unusual bleeding?Impotence?
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Genitourinary – Reproductive Prostate problems?Age when sexually active?Sexual partners? Any new ones?Pain with sex?Change in libido?
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Genitourinary – ReproductiveFertility problems?Pain in breasts? Lumps?Pain or masses in testicles?Practices self-examination?
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MusculoskeletalHistory of injuries or diseases?Back Pain?Limb or joint pain?Myalgias?Change in gait or balance?Neuropathies?
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MusculoskeletalWeakness?Assymmetrical strength/reflexes?Pain?Swelling?Spasms?
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EndocrineHistory of endocrine disorders?Excessive thirst, hunger, frequent urination?Cuts or sores that are slow to heal?Unexplained weight gain or loss?Changes in skin texture or color?Exopthalmos?
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EndocrineThinning or brittleness of hair?Increase in facial or body hair?Fatique?Insomnia?Nervousness?Palpitations?
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EndocrineGrowth normal for age?Changes in hair patterns?Change in menstrual patterns?
Regular or irregular?Weight loss or gain?Cold or heat intolerances?
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PsychosocialAny history of psychiatric problems?Marital status?Use of illicit drugs?Smoker?Alcohol?Ethnic/cultural background?
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Psychosocial?Occupation? If retired….from what profession?Educational level?Religious preference?Usual language?Health insurance?Difficulty sleeping, anxiety, depression, or fatigue?
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PsychosocialFamily/Marital problemsNumber of persons in householdIncome level/housingHealth habits, exercise, gambling, etc..