HEENT Review of Systems-1

GI:

-any problems with your stomach or belly lately? like nausea, vomiting, diarrhea, pain, or constipation? -do you have heartburn? -tell me about your bowel habits? have they changed recently or have you noticed blood or black colored stools? -do you used antacids or laxatives?

neck:

-"swollen glands" -goiter -lumps -pain -stiffness

skin:

-any rashes, sores, or bumps anywhere? -do you bruise easily? -any moles that are changing in shape, color, size?

general:

-any recent fever, chills, and night sweats? -have you gained or lost a lot of weight without trying recently? -have you felt unusually tired or sleepy recently?

cardiovascular:

-"heart trouble" -high blood pressure -rheumatic fever -heart murmur -chest pain or discomfort -palpitations -shortness of breath -need to use pillows at night to ease breathing -need to sit up at night to ease breathing -swelling in the hands, ankles, or feet -results of past electrocardiograms or other cardiovascular tests

endocrine:

-"thyroid trouble" -heat or cold intolerance -excessive sweating -excessive thirst or hunger -polyuria -change in glove or shoe size

start with:

-a fairly general question as you address each of the different systems

genital (female):

-age at 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 DES from maternal use during pregnancy (linked to cervical carcinoma) -vaginal discharge, itching, sores, lumps -STIs and treatment -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 -concerns on HIV infection

hematologic:

-anemia -easy bruising or bleeding -past transfusions -transfusion reactions

psychiatric:

-any mood changes? -do you feel down or depressed? -do you see things or hear things others cannot?

ENT/Mouth:

-any problems with a stuffy or runny nose? -any recent sore throat or sores in your mouth? -any problems with your teeth or gums like pain, bleeding, lose teeth?

neurologic:

-changes in mood, attention, or speech -changes in orientation, memory, insight, or judment -headache -dizziness -vertigo -fainting -black-outs -weakness -paralysis -numbness or loss of sensation -tingling or "pins and needles" -tremors or any involuntary movements -seizures

throat:

-condition of teeth and gums -bleeding gums -dentures, if any, and how do they fit -last dental examination -sore tongue -dry mouth -frequent sore throats -hoarseness

respiratory:

-cough -sputum (color, quantity; presence of blood or hemoptysis) -shortness of breath -wheezing -pain with deep breaths -last chest x-ray -may wish to include asthma, bronchitis, emphysema, pneumonia, tuberculosis

CV/peripheral vascular:

-do you ever have chest pains? nature of chest pains and associated symptoms? -do you every feel like your heart is racing or skips a beat? -do you have any pain in your legs or hips when you walk? does it get worse the further you walk?

endocrine/hematologic:

-do you have an intolerance to heat or cold? -do you have frequent urination associated with thirst? -do you bleed/bruise easily?

respiratory:

-do you have any trouble catching your breath or feel short of breath? -do you have trouble breathing after walking a little ways? -any new cough or coughing anything up? what's it look like?

urinary:

-frequency of urination -polyuria -nocturia -urgency -burning or pain during urination -blood in urine -urinary infections -kidney or flank pain -kidney stones -ureteral colic -suprapubic pain -incontinence -in males, reduce caliber or force of the urinary stream, hesitancy, dribbling

nose and sinuses:

-frequent colds -nasal stuffiness -discharge -itching -hay fever -nosebleeds -sinus trouble

head/neuro:

-have you been dizzy or felt like the room is spinning? -have you fainted or passed out recently? -do you have headaches? are they more frequent/less frequent than normal?

for each regional "system" ask:

-have you ever had any...?

GU/genital:

-have you had any changes in the amount of times you go to the bathroom in a day? -do you have to get up at night to go to the bathroom? -any pain or blood when you urinate?

musculoskeletal:

-have you had any recent muscle cramps? -have you had any muscle weakness or stiffness? -what about pain or stiffness in your knees, hands, back, or hips?

eyes:

-have you head problems with your eyes recently? like blurry vision, pain, watery eyes, redness or itching? -how is your vision? -do you wear glasses or contact lenses?

breast:

-have you noticed any lumps, pain, or tenderness in your breast or discharge from your nipples? -any areas of color changes on your breasts? -have you ever had a mammogram? when was your last one?

head:

-headache -head injury -dizziness -lightheadedness

ears:

-hearing -tinnitus -vertigo -earaches -infection -discharge -if hearing is decreased, use or nonuse of hearing aids

genital (male):

-hernias -discharge from or sores on the penis -testicular pain or masses -scrotal pain or swelling -history of sexually transmitted infections and their treatments -sexual habits, interest, function, satisfaction, birth control, condom use, and problems -concerns about HIV

peripheral vascular:

-intermittent leg pain with exertion -leg cramps -varicose veins -past clots in the veins -swelling in calves, legs, or feet -color change in fingertips or toes during cold weather -swelling with redness or tenderness

breasts:

-lumps -pain -discomfort -nipple discharge -self-examination practices

then shift to:

-more specific questions about systems that may be a concern

remember that major health events discovered during the Review of Systems should be:

-moved to the Present Illness or Past History in your write up

musculoskeletal:

-muscle or joint pain, stiffness -arthritis -gout -backache -if present, describe location of affected joints or muscles -any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity -include timing of symptoms, duration -history of trauma -neck or low back pain -joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness

psychiatric:

-nervousness -tension -mood -depression -memory change -suicidal ideation -suicide plans or attempts -past counseling, psychotherapy, or psychiatric admissions

neck/lymphatics:

-notice any new lumps or bumps on your neck? -is their any pain when you move your neck in any direction? -is your neck sore, painful, or stiff?

the need for additional questions will vary depending on:

-patient's age -complaints -general state of health -your clinical judgement

skin:

-rashes -lumps -sores -itching -dryness -changes in color -changes in hair or nails -changes in size or color of moles

it is helpful to prepare the patient by saying:

-the next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything

review of systems:

-think about asking a series of questions going from head-to-toe

gastrointestinal:

-trouble swallowing -heartburn -appetite -nausea -bowel movements -stool color and size -change in bowel habits -pain with defecation -rectal bleeding or black or tarry stools -hemorrhoids -constipation -diarrhea -abdominal pain -food intolerance -excessive belching or passing gas -jaundice -liver -gallbladder trouble -hepatits

the review of systems questions may:

-uncover problems that the patient has overlooked

general:

-usual weight -recent weight change -clothing that fits more tightly or loosely than before -weakness -fatigue -fever

eyes:

-vision -glasses or contact lenses -last examination -pain -redness -excessive tearing -double or blurred vision -spots -specks -flashing lights -glaucoma -cataracts

-general -skin -head/neuro -eyes -ENT/mouth -Neck/lymphatic -breast -respiratory -CV/peripheral vascular -GI -GU/genital -musculoskeletal -psychiatric -endocrine/hematologic

Review of systems (14 systems):