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Review of systems
| Question | Answer |
|---|---|
| The presence of _____ disease or ____ disease would call for re-evaluation of the surgical and anesthetic regimen in terms of the patients ability to withstand the stress involved. | Heart disease or lung disease |
| _____ may compromise the patients ability to heal. | Diabetes |
| _____ disease may cause bleeding complications or an inability to metabolize some prescribed medications | Liver disease |
| _____ and _____ diseases may affect the patients ability to undergo anesthesia and respond to stress. | Thyroid and adrenal diseases |
| _____ disease may prevent medications from being eliminated from the body, resulting in toxic drug effects. | Liver disease |
| Medical history taking #1 key question | If the patient is currently under a physicians care for any illness or surgical problem or severe accident. |
| Dedicated history taking #2 key question | Vital to asses prior hospitalizations and operations for the patient as they may have impact on surgical and anesthetic decision-making. |
| Medical history taking #3 key question | To know whether the patient is taking any medication at the present time or has taken any medications prescribed by a doctor in the past year. |
| Review of systems - general | Weight loss, loss of appetite, fatigue and weakness. They may indicate a disease affecting metabolism, such as thyroid problems, diabetes, liver disease, digestive problems or malignant disease. |
| Review of systems - skin | Bleeding, bruising or changes in color - might indicate blood dyscrasias( clotting disorders), liver disease or adrenal disease. |
| Review of systems - cardiovascular | Headaches, nosebleeds, shortness of breath, dizziness, chest or arm pain, or swollen hands, ankles or feet - might indicate BP problems of heart disease. |
| Review of systems - pulmonary | Shortness of breath, chronic cough, wheezing, dizziness or productive cough - might indicate obstructive lung disease or malignancy. |
| Review of systems - gastrointestinal | Nausea, vomiting, diarrhea, constipation, loss of appetite, changes in taste or difficulty in swallowing - might indicate liver disease, drug abuse, inflammatory bowel disease |
| Review of systems - genitourinary | Painful urination(dysuria), frequent urination(polyuria), blood in urine(hematuria), incontinence or discharge- might indicate an infection in the urinary system, diabetes or malignancy. |
| Review of systems - neurologic | Weakness in extremities, headaches, visual disturbances, history of projectile vomiting and unexplained pain and/or numbness in the area of the body- might indicate an undiagnosed neurological disorder |
| Review of systems - musculoskeletal | Weakness of extremities, atrophy of muscles or frequent cramping of muscles- may indicate a metabolic disorder or malabsorptive syndrome, nerve damage, or one of the muscle or collagen diseases. |
| Family history | Determination of a family history of certain diseases may offer info. As to risks for the patient. Ex: family history of malignant hyperthermia, which would lead to increased anesthetic risk in the office. |
| Social history | Alcohol, tobacco or recreational drug use. Drugs, such as cocaine or amphetamines, cause increased risks with general anesthesia. |
| Helps with Type 1 diabetes | The combo. of rapidly acting insulin analog such as "Humalog" and a long-acting analog such as "Lantus" allows for more physiologic insulin replacement. |
Created by:
Oliverhart
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