ROS review of systems

http://medical-transcription-sample-reports.blogspot.com/2010/12/physical-exam-section-words-and-phrases.html

REVIEW OF SYSTEMS:

GENERAL:  The patient complains of fatigue. No headaches or dizzy spells.

HEENT:  The patient does have glaucoma. She has decreased vision and is blind in the right. Sinuses:  No complaints.

CARDIOPULMONARY:  She gets swelling of the legs but no chest pain. She does have shortness of breath, no wheezing.

GASTROINTESTINAL:  She has frequent heartburns. Has known gastroparesis. Denies both diarrhea and constipation, blood or mucus.

GENITOURINARY:  She denies dysuria, bleeding and incontinence.

MUSCULOSKELETAL: She has a lot of arthritic complaints including stiffness, weakness.

She has slow healing. The patient seems to be feeling well. 

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

REVIEW OF SYSTEMS:  The patient denies any fever, weight change. Denies any sore throat, ear pain, rhinorrhea. Denies any double vision, blurred vision or eye pain. Denies any shortness of breath, cough or pleuritic chest pain. The patient denies any nausea, vomiting or diarrhea. The patient does not have any dysuria, frequency or urgency. The patient does have myalgias in the back and legs from the sickle cell pain but no bony tenderness. The patient does have a history of anemia and has required transfusions in the past. He denies any bleeding or easy bruising.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  As per HPI.

HEENT:  Eyes:  No diplopia or blurred vision. ENT:  No earache, sore throat or runny nose.

CARDIOVASCULAR:  No pressure, squeezing, strangling, tightness, heaviness or aching about the chest, neck, axilla or epigastrium.

RESPIRATORY:  No cough, shortness of breath, PND or orthopnea.

GASTROINTESTINAL:  No nausea, vomiting or diarrhea.

GENITOURINARY:  No dysuria, frequency or urgency.

MUSCULOSKELETAL:  As per HPI.

SKIN:  No change in skin, hair or nails.

NEUROLOGIC:  No paresthesias, fasciculations, seizures or weakness.

PSYCHIATRIC:  No disorder of thought or mood.

ENDOCRINE:  No heat or cold intolerance, polyuria or polydipsia.

HEMATOLOGICAL:  No easy bruising or bleeding. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  Denies fevers, denies recent illnesses. EYES:  Denies any vision changes. ENT:  Denies any throat pain. NECK:  Denies any neck pain. CARDIOVASCULAR:  Denies chest pain. Denies palpitations. RESPIRATORY:  Denies shortness of breath, denies cough, denies history of asthma or any pulmonary illnesses. GASTROINTESTINAL:  Positive for nausea as described above which has now resolved. Negative for emesis. Positive for abdominal pain. Negative for diarrhea. GENITOURINARY:  Negative for dysuria. Negative for urinary frequency or urgency. MUSCULOSKELETAL:  Negative for extremity pains or joint discomfort. NEUROLOGIC:  No change in sensation or paresthesias. SKIN:  No rashes. Abdominal incisions are healed without any dehiscence, fluid leaking or pain.