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Revisión-de-Sistemas

Revision de Sistemas

TermDefinition
General Fevers, chills, night sweats, malaise, weakness, fatigue, wt loss/gain
Skin Color changes, dryness, lesions, masses, rashes, itching.
Hair Hair loss, excess, texture changes, use of dyes or perms.
Nails Changes in appearance, texture changes.
Head & Face Headaches, facial pain
Eyes Current vision, pain, redness, discharge, excessive tearing or dryness, Hx of infections, lid swelling, use of corrective or prosthetic devices, visual problems.
Ears Current hearing, pain, discharge, tinnitus, hearing changes, protracted exposure to loud noises, care habits, use of hearing aids.
Nose & Sinuses Current olfactory ability, pain, discharge, itching, nosebleeds, Fx of colds or sinus infections, sneezing.
Mouth Pain, lesions, bleeding in lips, mouth, gums, tongue, throat; Tooth pain, loose teeth, caries; dentures, bridges; difficulty chewing; dryness or excessive salivation, tasting ability changes, hoarseness, voz changes, dental care (brush, floss).
Neck & Lymph nodes Stiffness, pain, masses, swelling, tenderness.
Female Breasts Recent changes in size/appearance, masses, swelling, tenderness, pain, discharge, breastfeeding Hx, BSE pattern.
Male Breasts Recent changes in size/appearance, Lesions.
Respiratory Cough, sputum production, bloody sputum, wheezing, SOB, dyspnea on exertion, limitations.
Cardiac Chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, HTN, murmurs, functional limitations.
Gastrointestinal Appetite, food intolerance, difficulty swallowing, N/V, heartburn, pain, abd swelling/distention, bowel movement changes, rectal pain, black stools, hemorrhoids, excessive eructation or flatulence, laxatives, limitations.
Urinary Fx, nocturia, dysuria, hematuria, urgency, stream force, hesitancy, incontinence, dribbling, Hx of infections o stones, limitations.
Female Genitoreproductive 1 Menarche, bleeding (Fx, duration, amt), last menstrual period, painful menses, premenstrual Sx, DES exposure, menopausal age + Sx, post-menopausal bleeding, discharge, itching, lesions.
Female Genitoreproductive 2 Intercourse pain, Hx STDs, GPA, preg complications, birth control, Sexual Hx, Libido or orgasm changes, Hx Sx Abse. Gravida = Preg. Para = Births. Ab Abortus.
Male Genitoreproductive Discharge; lesions; testicular pain, lumps, swelling; hernias; impotence; erectile dysfunction; Sx Hx; Libido change, Hx Sx Abse.
Peripheral Vascular Leg cramps, Pain with amb, hands/feet color changes, varicose veins, leg hair loss, Hx phlebitis o blood clots, edema, limitations.
Musculoskeletal Muscle o joint pain, swelling, redness, stiffness, weakness, deformities, limitations.
Neurologic Vertigo, syncope, ataxia, seizures, weakness, paralysis, numbness, tingling, sensation loss, tremors, involuntary movements, gait change, memory changes, limitations.
Hematological Easy bruising o prolonged bleeding, anemia, Hx transfusions.
Endocrine Excessive sweating, thirst, hunger, urination; heat o cold intolerance.
Psychological Self-concept, stress, goals, values.
Sociological Education, finances, friends, family, significant social transitions.
General Meds, allergies, immunizations.
HPI OLDCARTS: Onset, Location, Duration, Characteristics, Associated/Aggravating, Relieving, Tx, Summary.
HPI PQRSTU: Provocative / Palliative, Quality / Quantity, Region / Radiation, Severity Scale, Timing (onset, duration, Fx), Understand Pt's perception of CC (What does it mean?)
Past Med Hx Chronic conditions, injuries, hospitalizations, surgeries, childhood Dx.
Family Hx HTN, CardioVasc, Dyslipidemia, Cancer, DM, Substance abuse, Mental health dz, stroke, Kidney dz, arthritis, anemia, asthma, headaches, allergies, murmurs, glaucoma. Docx age @ death, health status, cause of death.
Health Maintenance Habits, Screenings.
Habits (Health Maintenance) Exercise, Sleep, Nutrition, Caffeine, Alcohol, Tobacco, Recreational drugs, Seat belt, Smoke/CO detectors, Occupational hazard exposures, sunscreen, helmets, House/gun safety.
Screenings (Health Maintenance) Dental, Eye, Gyn, Testicular, Mammography, Rectal, Cholesterol, Chest x-ray, Electrocardiogram, Immune (Mantoux = TB), Bone densitometry.
ROS General, Skin, Hair, Nails, Head & Face, Eyes, Ears, Nose, Sinuses, Mouth, Neck & Lymph nodes, Breasts, Respiratory, Cardiac, GI, GU Reprod, Peripheral Vascular, Musculoskeletal, Neuro, Heme, Endocrine, Psych, Sociological.
Adult Health Hx General, CC, HPI, past Med Hx, Fam Hx, Health Maintenance, ROS.
Created by: c4758210
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