Transcript Review of Systems

“Review of Systems”
(ROS)
SYSTEMATIC PROBLEM ASSESSMENT
&
SUBJECTIVE DATA
J. Carley, MSN, MA, RN, CNE
Fall, 2009
Example of Electronic Health Record (EHR)
Review of Systems Screen
For each Symptom
 Onset
 Duration
 Severity
 Alleviating Factors
 Aggravating Factors
Helpful questions by system…………….
 Skin – Integumentary System
Any 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?
Helpful questions by system
 Head and Neck
Any headaches?
Dizziness?
Syncope?
Head injuries?
Loss or change in consciousness?
Thyroid problems
Swollen glands?
Pain or stiffness of neck
Any problems swallowing?
Helpful questions by system
 Eyes, Ears, Nose, Throat – EENT
Visual acuity problems? Changes?
Last eye exam?
Pain ? Where?
Hearing loss?
Discharge or drainage?
Vertigo?
Tinnitus?
Sense of Smell?
Helpful questions by system
 Eyes, Ears, Nose, Throat – EENT
Frequent colds?
Epistaxis?
Postnasal drainage?
Allergies?
Recurrence of symptoms?
Change in voice?
Sore throat?
Bleeding or Swelling of the gums?
Helpful questions by system
 Eyes, Ears, Nose, Throat – EENT
Tooth abscesses or extractions?
Swelling?
Ulcers in mouth?
Disturbance of taste?
Last dental exam?
Helpful questions by system
Respiratory System
Last chest x-ray?
Respiratory allergies?
Smoker? Tobacco or others – how much?
Dyspnea? When?
Pain with breathing?
Orthopnea?
Helpful questions by system
Respiratory System
Any cough?
Sputum production?
Hemoptysis?
Wheezing?
History of asthma, bronchitis,emphysema?
Helpful questions by system
Respiratory System
Labored respirations?
Frequent colds?
Exposure to environmental hazards?
TB risk?
Helpful questions by system
Cardiovascular
Any chest pain?
Any dizziness?
Any syncope?
Palpitations?
Dyspnea?
Helpful questions by system
Cardiovascular
Hypertension?
Familial risks?
Smoker?
Previous cardiac problems?
Last EKG or cardiac tests?
Edema? Where?
Helpful questions by system
 Cardiovascular
Varicosities = varicose veins?
Peripheral neuropathies?
History of DVT?
Swelling of feet, legs, hands
Pressure, pain or heaviness in arms, jaw, or chest
Helpful questions by system
 Cardiovascular
Leg pain or cramps?
Bleeding problems?
Anemias?
SOB with exertion?
Helpful questions by system
 Breast & Chest
Pain/tenderness?
Swelling?
Discharge?
New assymmetry?
Last mammogram?
Lumps?
Helpful questions by system
 Neurological
Loss of consciousness?
Speech difficulty?
Change in processing information?
Swallowing difficulty?
Confusion?
Helpful questions by system
 Neurological
Helpful questions by system
 Neurological
Weakness?
New Falls?
Dropping items – weak grip?
Change in balance, gait?
Helpful questions by system
 Neurological
Blurred vision?
Numbness or tingling of extremities?
Changes in sensory perception?
Helpful questions by system
 Gastrointestinal
Dyspepsia?
Diarrhea?
Constipation?
Nausea or vomitting?
Allergies/ food intolerances?
Abdominal pain?
Helpful questions by system
 Gastrointestinal
Bloating?
Excess flatus?
Belching?
Change in color of stools?
Change in consistency of stools?
Pain with eating or defecating?
Helpful questions by system
 Genitourinary
History of kidney or bladder disease?
Urinary frequency?
Burning?
Nocturia?
Changes in urine color?
Clarity or odor of urine?
Helpful questions by system
 Genitourinary
Pain?
Excessive thirst?
Swelling of legs, hands, eyelids?
Dietary intake of calcium?
Chills or fever?
inability to urinate?
Helpful questions by system
 Genitourinary
Hesitancy of urination?
Incontinence?
Helpful questions by system
 Genitourinary – Reproductive
Female history of pregnancy G: P: A:
Onset of menses?
Last menstrual cycle?
Onset of menopause?
Unusual bleeding?
Impotence?
Helpful questions by system
 Genitourinary – Reproductive
Prostate problems?
Age when sexually active?
Sexual partners? Any new ones?
Pain with sex?
Change in libido?
Helpful questions by system
 Genitourinary – Reproductive
Fertility problems?
Pain in breasts?
Lumps?
Pain or masses in testicles?
Practices self-examination?
Helpful questions by system
 Musculoskeletal
History of injuries or diseases?
Back Pain?
Limb or joint pain?
Myalgias?
Change in gait or balance?
Neuropathies?
Helpful questions by system
 Musculoskeletal
Weakness?
Assymmetrical strength/reflexes?
Pain?
Swelling?
Spasms?
Helpful questions by system
 Endocrine
History 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?
Helpful questions by system
 Endocrine
Thinning or brittleness of hair?
Increase in facial or body hair?
Fatique?
Insomnia?
Nervousness?
Palpitations?
Helpful questions by system
 Endocrine
Growth normal for age?
Changes in hair patterns?
Change in menstrual patterns?
Regular or irregular?
Weight loss or gain?
Cold or heat intolerances?
Helpful questions by system
 Psychosocial
Any history of psychiatric problems?
Marital status?
Use of illicit drugs?
Smoker?
Alcohol?
Ethnic/cultural background?
Helpful questions by system
 Psychosocial?
Occupation? If retired….from
what profession?
Educational level?
Religious preference?
Usual language?
Health insurance?
Difficulty sleeping, anxiety, depression, or fatigue?
Helpful questions by system
 Psychosocial
Family/Marital problems
Number of persons in household
Income level/housing
Health habits, exercise, gambling, etc..