Term | Definition |
general overall health state | weight changes?
weaknesses?
Malaise?
Fever?
Chills?
Sweats?
Night sweats? |
skin | Disease (eczema, psoriasis, hives)?
Pigment changes?
mole changes?
Excessive bruising?
Excessive dryness/diaphoresis?
Rash/lesion? |
Head | HA?
Head Injury?
Syncope?
Vertigo? |
Nose & Sinuses | discharge/characteristics?
Sinus pain?
Nasal obstruction?
nosebleeds?
Allergies/hayfever?
Sense of smell changes? |
eyes | diplopia?
vision difficulties?
eye pain?
Redness/swelling?
Watering/discharge?
Glaucoma?
cataracts? |
Mouth/throat | Mouth pain?
frequent sore throats?
Bleeding gums?
Toothaches?
Mouth/tongue lesions?
Dysphagia?
Hoarseness/voice changes?
altered taste? |
Ears | Earaches?
Infections?
Discharge/characteristics?
tinnitus?
vertigo? |
hair | recent loss?
changes in texture? |
Neck | pain?
Limited ROM?
Lumps/swelling?
Enlarged/tender nodes?
Goiter? |
breasts | pain?
lumps?
nipple discharge?
rash? |
Respiratory system | lung dz? (asthma, emphysema, bronchitis, pneumonia, Tb)
Chest pain when breathing?
Wheezing/noisy breathing?
SOB?
Cough?
Sputum amount/color?
hemoptysis
toxin/pollution exposure? |
Axilla | tenderness?
lumps/swelling?
rash? |
Gastrointestinal | appetite?
food intolerances?
dysphagia?
heartburn?
Indigestion?
Abdominal pain?
Pyrosis?
Nausea/vomit?
Flatulence?
BM changes/characteristics?
rectal bleeding?
hemorrhoids/fistula? |
cardiovascular | precordial pain?
palpitations?
cyanosis?
dyspnea on exertion?
Orthopena?
Paroxysmal nocturnal dyspnea?
Nocturia?
edema?
heart murmur?
HTN?
CAD?
Anemia? |
Peripheral vascular | Coldness?
Numbness/tingling?
leg swelliing?
hands/feet discoloring?
Varicose veins?
intermittent claudication?
thrombophlebitis?
Ulcers? |
Urinary | Frequency per day? Night?
Urgency?
Pain?
Polyuria? <500mL
Oliguria? >400mL
Hesitancy?
Narrowing of stream?
Change in color/clarity?
Incontinence?
Kidney dz (stones, UTI, Prostate)?
Pain in flank/groin/suprapubic region/low back? |
Male genital | penis/testicular pain?
sores/lesions?
Discharge?
Lumps?
Hernia? |
Female Genitelia | Menstruation hx?
vaginal itching/discharge?
postmenopausal bleeding?
last PAP exam? |
Sexual health | currently having sexual intercourse?
using b/c? method?
has partner had any STDs? |
musculoskeletal system | arthritis/gout?
joint paint/stiffness/swelling?
Deformities?
Limited ROM?
noise with joint movement?
muscle pain/cramping/weakness?
steady gait?
back pain? |
Neurologic system | History seizure disorder?
fainting/stroke/blackouts?
weakness/tremors/tics?
paralysis/coordination problems?
Memory problems?
mood changes/depression/hallucinations? |
Hemotologic system | bleeding tenancies?
excessive bruising?
node swelling?
radiation/toxin exposure?
blood transfusions? |
Endocrine system | DM? (polyuria, polydipsia, polyphagia)?
Thyroid dz?
Intolerance to heat/cold?
Change skin pigment/texture?
Excessive sweating?
Abnormal hair distribution?
Nervousness?
Tremors? |
How many systems in ROS (10) | respiratory system
cardiovascular systems
gastrointestinal systems
urinary system
male genital system
female genital system
musculoskeletal system
neurological system
endocrine system
hematopoiectic system |