Review of Systems

Understanding and using Review of Systems questions is often challenging for beginning students. Think about asking series of questions going from "head to toe." It is helpful to prepare the patient for the questions to come by saying, "The next part of the history may feel like a million questions, but they are important and I want to be thorough." Most Review of Systems questions pertain to symptoms, but on occasion some clinicians also include diseases like pneumonia or tuberculosis. (If the patient remembers important illnesses as you ask questions within the Review of Systems, you should

§:cord or present such important illnesses as part of the Present Illness or ast History.)

Start with a fairly general question as you address each of the different systems. This focuses the patient's attention and allows you to shift to more ■specific questions about systems that may be of concern. Examples of starting questions are: "How are your ears and hearing?" "How about your lungs and breathing?" "Any trouble with your heart?" "How is your digestion?"

"How about your bowels?" Note that you will vary the need for additional questions depending on the patient's age, complaints, general state of health, and your clinical judgment.

The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the present illness. Significant health events, such as a major prior illness or a parent's death, require full exploration. Remember that major health events should be moved to the present illness or past history in your write-up. Keep your technique flexible. Interviewing the patient yields a variety of information that you organize into formal written format only after the interview and examination are completed.

Some clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. However, if there are multiple symptoms, the flow of both the history and the examination can be disrupted and necessary note-taking becomes awkward. Listed below is a standard series of review-of-system questions. As you gain experience, the "yes or no" questions, placed at the end of the interview, will take no more than several minutes.

General. Usual weight, recent weight change, any clothes that fit more tightly or loosely than before. Weakness, fatigue, fever.

Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails.

Head, Eyes, Ears, Nose, Throat (HEENT). Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.

Q Neck. Lumps, "swollen glands," goiter, pain, or stiffness in the neck.

Breasts. Lumps, pain or discomfort, nipple discharge, self-examination

^practices.

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