Review of Systems

  • Skin – bruising, discoloration, pruritus, birthmarks, moles, ulcers, decubiti, changes in the hair or nails, sun exposure and protection.
  • Hematopoietic –  spontaneous or excessive bleeding, fatigue, enlarged or tender lymph nodes, pallor, history of anemia.
  • Head and Face – pain, traumatic injury, ptosis.
  • Ears – tinnitus, change in hearing, running or discharge from the ears, deafness, dizziness.
  • Eyes – change in vision, pain, inflammation, infections, double vision, scotomata, blurring, tearing.
  • Mouth and Throat – dental problems, hoarseness, dysphagia, bleeding gums, sore throat, ulcers or sores in the mouth.
  • Nose and Sinuses – discharge, epistaxis, sinus pain, obstruction.
  • Breasts – pain, change in contour or skin color, lumps, discharge from the nipple(s).
  • Neck
  • Heart
  • Lungs
  • Abdomen
  • Extremities
  • Neurological
  • MSK
  • Vascular 
  • Respiratory tract – cough, sputum, change in sputum, night sweats, nocturnal dyspnea, wheezing.
  • Cardiovascular System – chest pain, dyspnea, palpitations, weakness, intolerance of exercise, varicosities, swelling of extremities, known murmur, hypertension, asystole.
  • Gastrointestinal System – nausea, vomiting, diarrhea, constipation, quality of appetite, change in appetite, dysphagia, gas, heartburn, melena, change in bowel habits, use of laxatives or other drugs to alter the function of the gastrointestinal tract.
  • Urinary Tract – dysuria, change in color of urine, change in frequency of urination, pain with urgency, incontinence, edema, retention, nocturia.
  • Genital Tract (Female) – menstrual history, obstetric history, contraceptive use, discharge, pain or discomfort, pruritus, history of venereal disease, sexual history.
  • Genital Tract (Male) – penile discharge, pain or discomfort, pruritus, skin lesions, hematuria, history of venereal disease, sexual history.
  • Skeletal System – heat; redness; swelling; limitation of function; deformity; crepitation: pain in a joint or an extremity, the neck, or the back, especially with movement.
  • Nervous System – dizziness, tremor, ataxia, difficulty in speaking, change in speech, paresthesia, loss of sensation, seizures, syncope, changes in memory.
  • Endocrine System – tremor, palpitations, intolerance of heat or cold, polyuria, polydipsia, polyphagia, diaphoresis, exophthalmos, goiter.
  • Psychologic Status – nervousness, instability, depression, phobia, sexual disturbances, criminal behavior, insomnia, night terrors, mania, memory loss, perseveration, disorientation
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