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Review of systems

QuestionAnswer
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