“Review of Systems” (ROS)

Review of Systems

Systematic Problem Assessment&Subjective DataReview of Systems(ROS)

J. Carley, MSN, MA, RN, CNEFall, 20091

2Example of Electronic Health Record (EHR)Review of Systems Screen

3For each SymptomOnsetDurationSeverityAlleviating FactorsAggravating Factors

4Helpful questions by system.Skin Integumentary SystemAny changes in color?Any pain or enlargement?Any itching or rashes?History of scarring or diseases?Sores that will not heal?Allergies to environmental allergens or food?Any new medications?

5

6

7Helpful questions by systemHead and NeckAny headaches?Dizziness?Syncope?Head injuries?Loss or change in consciousness?Thyroid problemsSwollen glands?Pain or stiffness of neckAny problems swallowing?

8Helpful questions by systemEyes, Ears, Nose, Throat EENTVisual acuity problems? Changes?Last eye exam?Pain ? Where?Hearing loss?Discharge or drainage?Vertigo?Tinnitus?Sense of Smell?

9Helpful questions by systemEyes, Ears, Nose, Throat EENTFrequent colds?Epistaxis?Postnasal drainage?Allergies?Recurrence of symptoms?Change in voice?Sore throat?Bleeding or Swelling of the gums?

10Helpful questions by systemEyes, Ears, Nose, Throat EENTTooth abscesses or extractions?Swelling?Ulcers in mouth?Disturbance of taste?Last dental exam?

11Helpful questions by systemRespiratory SystemLast chest x-ray?Respiratory allergies?Smoker? Tobacco or others how much?Dyspnea? When?Pain with breathing?Orthopnea?

12Helpful questions by systemRespiratory SystemAny cough?Sputum production?Hemoptysis?Wheezing?History of asthma, bronchitis,emphysema?

13Helpful questions by systemRespiratory SystemLabored respirations?Frequent colds?Exposure to environmental hazards?TB risk?

14Helpful questions by systemCardiovascularAny chest pain?Any dizziness?Any syncope?Palpitations?Dyspnea?

15Helpful questions by systemCardiovascularHypertension?Familial risks?Smoker?Previous cardiac problems?Last EKG or cardiac tests?Edema? Where?

16Helpful questions by system CardiovascularVaricosities = varicose veins?Peripheral neuropathies?History of DVT?Swelling of feet, legs, handsPressure, pain or heaviness in arms, jaw, or chest

17Helpful questions by systemCardiovascularLeg pain or cramps?Bleeding problems?Anemias?SOB with exertion?

18Helpful questions by systemBreast & ChestPain/tenderness?Swelling?Discharge?New assymmetry?Last mammogram?Lumps?

19

20Helpful questions by systemNeurologicalLoss of consciousness?Speech difficulty?Change in processing information?Swallowing difficulty?Confusion?

21Helpful questions by systemNeurological

22Helpful questions by systemNeurologicalWeakness?New Falls?Dropping items weak grip?Change in balance, gait?

23Helpful questions by systemNeurologicalBlurred vision?Numbness or tingling of extremities?Changes in sensory perception?

24

25Helpful questions by systemGastrointestinalDyspepsia?Diarrhea?Constipation?Nausea or vomitting?Allergies/ food intolerances?Abdominal pain?

26Helpful questions by systemGastrointestinalBloating?Excess flatus?Belching?Change in color of stools?Change in consistency of stools?Pain with eating or defecating?

27Helpful questions by systemGenitourinaryHistory of kidney or bladder disease?Urinary frequency?Burning?Nocturia?Changes in urine color?Clarity or odor of urine?

28Helpful questions by systemGenitourinaryPain?Excessive thirst?Swelling of legs, hands, eyelids?Dietary intake of calcium?Chills or fever?inability to urinate?

29Helpful questions by systemGenitourinaryHesitancy of urination?Incontinence?

30Helpful questions by systemGenitourinary ReproductiveFemale history of pregnancy G: P: A:Onset of menses?Last menstrual cycle?Onset of menopause?Unusual bleeding?Impotence?31Helpful questions by systemGenitourinary Reproductive Prostate problems?Age when sexually active?Sexual partners? Any new ones?Pain with sex?Change in libido?

32Helpful questions by systemGenitourinary ReproductiveFertility problems?Pain in breasts? Lumps?Pain or masses in testicles?Practices self-examination?

33Helpful questions by systemMusculoskeletalHistory of injuries or diseases?Back Pain?Limb or joint pain?Myalgias?Change in gait or balance?Neuropathies?

34Helpful questions by systemMusculoskeletalWeakness?Assymmetrical strength/reflexes?Pain?Swelling?Spasms?

35Helpful questions by systemEndocrineHistory of endocrine disorders?Excessive thirst, hunger, frequent urination?Cuts or sores that are slow to heal?Unexplained weight gain or loss?Changes in skin texture or color?Exopthalmos?

36Helpful questions by systemEndocrineThinning or brittleness of hair?Increase in facial or body hair?Fatique?Insomnia?Nervousness?Palpitations?

37Helpful questions by systemEndocrineGrowth normal for age?Changes in hair patterns?Change in menstrual patterns? Regular or irregular?Weight loss or gain?Cold or heat intolerances?

38Helpful questions by systemPsychosocialAny history of psychiatric problems?Marital status?Use of illicit drugs?Smoker?Alcohol?Ethnic/cultural background?

39Helpful questions by systemPsychosocial?Occupation? If retired.from what profession?Educational level?Religious preference?Usual language?Health insurance?Difficulty sleeping, anxiety, depression, or fatigue?

40Helpful questions by systemPsychosocialFamily/Marital problemsNumber of persons in householdIncome level/housingHealth habits, exercise, gambling, etc..

41