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Wednesday, October 13, 2010

Review of Systems

Understanding and using Review of Systems questions is often challenging
for beginning students. Think about asking series of questions going from
"head to toe." It is helpful to prepare the patient for the questions to come
by saying, "The next part of the history may feel like a million questions,
but they are important and I want to be thorough." Most
Review of Systems
questions pertain to
diseases like pneumonia or tuberculosis. (If the patient remembers important
illnesses as you ask questions within the
record or present such important illnesses as part of the
symptoms, but on occasion some clinicians also includeReview of Systems, you shouldPresent Illness or
Past History.
Start with a fairly general question as you address each of the different systems.
This focuses the patient’s attention and allows you to shift to more
speci.c questions about systems that may be of concern. Examples of starting
questions are: "How are your ears and hearing?" "How about your lungs
and breathing?" "Any trouble with your heart?" "How is your digestion?"

"How about your bowels?" Note that you will vary the need for additional
questions depending on the patient’s age, complaints, general state of health,
and your clinical judgment.
The
overlooked, particularly in areas unrelated to the
health events, such as a major prior illness or a parent’s death, require full
exploration. Remember that
illness or past history in your write-up.
the patient yields a variety of information that you organize into formal
written format only after the interview and examination are completed.
Some clinicians do the
asking about the ears, for example, as they examine them. If the patient has
only a few symptoms, this combination can be ef.cient. However, if there
are multiple symptoms, the .ow of both the history and the examination can
be disrupted and necessary note-taking becomes awkward. Listed below is a
standard series of review-of-system questions. As you gain experience, the
"yes or no" questions, placed at the end of the interview, will take no more
than several minutes.
Review of Systems questions may uncover problems that the patient haspresent illness. Signi.cantmajor health events should be moved to the presentKeep your technique .exible. InterviewingReview of Systems during the physical examination,
General.
tightly or loosely than before. Weakness, fatigue, fever.
Usual weight, recent weight change, any clothes that .t more
Skin.
hair or nails.
Rashes, lumps, sores, itching, dryness, color change, changes in
Head, Eyes, Ears, Nose, Throat (HEENT).
dizziness, lightheadedness.
examination, pain, redness, excessive tearing, double vision, blurred vision,
spots, specks, .ashing lights, glaucoma, cataracts.
earaches, infection, discharge. If hearing is decreased, use or nonuse of
hearing aids.
itching, hay fever, nosebleeds, sinus trouble.
Head: Headache, head injury,Eyes: Vision, glasses or contact lenses, lastEars: Hearing, tinnitus, vertigo,Nose and sinuses: Frequent colds, nasal stuf.ness, discharge, orThroat (or mouth and pharynx):
Condition of teeth, gums, bleeding gums, dentures, if any, and how they
.t, last dental examination, sore tongue, dry mouth, frequent sore throats,
hoarseness.
Neck.
Lumps, "swollen glands," goiter, pain, or stiffness in the neck.
Breasts.
practices.
Lumps, pain or discomfort, nipple discharge, self-examination
Respiratory.
wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis,
emphysema, pneumonia, and tuberculosis.
Cough, sputum (color, quantity), hemoptysis, dyspnea,
Cardiovascular.
heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other
heart test results.
Gastrointestinal.
bowel movements, color and size of stools, change in bowel habits, rectal
bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal
pain, food intolerance, excessive belching or passing of gas. Jaundice,
liver or gallbladder trouble, hepatitis.
Trouble swallowing, heartburn, appetite, nausea,
Urinary.
or pain on urination, hematuria, urinary infections, kidney stones, incontinence;
in males, reduced caliber or force of the urinary stream, hesitancy,
dribbling.
Frequency of urination, polyuria, nocturia, urgency, burning
Genital.
pain or masses, history of sexually transmitted diseases and their treatments.
Sexual habits, interest, function, satisfaction, birth control methods,
condom use, and problems. Exposure to HIV infection.
menarche; regularity, frequency, and duration of periods; amount of bleeding,
bleeding between periods or after intercourse, last menstrual period;
dysmenorrhea, premenstrual tension; age at menopause, menopausal symptoms,
postmenopausal bleeding. If the patient was born before 1971, exposure
to diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal
discharge, itching, sores, lumps, sexually transmitted diseases and
treatments. Number of pregnancies, number and type of deliveries, number
of abortions (spontaneous and induced); complications of pregnancy; birth
control methods. Sexual preference, interest, function, satisfaction, any problems,
including dyspareunia. Exposure to HIV infection.
Male: Hernias, discharge from or sores on the penis, testicularFemale: Age at
Peripheral Vascular.
veins, past clots in the veins.
Intermittent claudication, leg cramps, varicose
Musculoskeletal.
backache. If present, describe location of affected joints or muscles, presence
of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation
of motion or activity; include timing of symptoms (for example, morning or
evening), duration, and any history of trauma.
Muscle or joint pains, stiffness, arthritis, gout, and
Neurologic.
or loss of sensation, tingling or "pins and needles," tremors or other involuntary
movements.
Fainting, blackouts, seizures, weakness, paralysis, numbness
Hematologic.
and/or transfusion reactions.
Anemia, easy bruising or bleeding, past transfusions
Endocrine.
excessive thirst or hunger, polyuria, change in glove or shoe size.
Thyroid trouble, heat or cold intolerance, excessive sweating,
Psychiatric.
change, suicide attempts, if relevant.
Nervousness, tension, mood, including depression, memory
Heart trouble, high blood pressure, rheumatic fever,
)

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