Review of Systems

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Warren E. Hill, MD, FACS Neal A. Nirenberg, MD, FACS East Valley Ophthalmology, Ltd. Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology 5620 E. Broadway Road Diplomate, American Board of Eye Surgery Cataract and Comprehensive Ophthalmology Mesa, Arizona 85206-1438 Cataract and Anterior Segment Surgery Telephone: (480) 981-6111 Facsimile: (480) 985-2426 Jonathan B. Kao, MD Yuri F. McKee, MD Internet www.doctor-hill.com Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology Cataract, Cornea and External Disease Cataract, Cornea and Anterior Segment Surgery Glaucoma Surgery and Management Review of Systems For new patients, established patients who may be having new problems, or patients we have not seen in a while, we need to update your overall medical health. In each area, if you are not having any difficulties please circle No problems. If you are experiencing any of the symptoms listed, please circle the ones that apply, or you may write in ones that may not be listed. If you have any questions, please ask one of our staff. Cardiovascular Ears/Nose/Throat Musculoskeletal Respiratory Chest pain Dizziness Back pain Cough Irregular heartbeat Hearing loss Joint pain Trouble breathing Shortness of breath Hoarseness Muscle aches Wheezing ________________ Ringing in ears Stiffness ________________ Sore throat Swelling ________________ ________________ No problems No problems No problems No problems Constitutional Hematologic Neurologic Skin Fatigue Bleeding Balance problems Hair loss Fever Bruising Headache Rash Night sweats Tender nodes Numbness Skin lesions Weakness ________________ Tingling _______________ Weight loss ________________ ________________ No problems No problems No problems No problems Genitourinary Metabolic Psychiatric Allergy Genital discharge Cold intolerance Anxiety Itching Genital lesions Excess hunger Depression Hives Painful urination Excessive thirst Insomnia Runny nose Urgency Frequent urination Irritability Seasonal allergies ________________ Heat intolerance Nervousness ________________ ________________ ________________ No problems No problems No problems No problems Blood Pressure Control Diabetes Control Good Good Borderline Borderline Poor Poor Unknown Unknown Not applicable Not applicable .

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A New Mother with Night Sweats
MedicineToday PEER REVIEWED CLINICAL CASE REVIEW A new mother with night sweats Commentary by CASE SCENARIO JOHN EDEN MB BS, FRCOG, FRANZCOG, CREI Sally is a 35-year-old woman who presents for her three-monthly contraceptive injection of depot medroxyprogesterone. She mentions in passing that since the birth of her second child, A 35-year-old woman has been experiencing nine months previously, she has been experiencing night sweats three or four times a week. She has no obvious focus of infec- night sweats since the birth of her second tion, no pain and no other systemic symptoms, although she child nine months previously. says she often feels very tired. She also reports that she is still producing some breast milk despite having stopped breastfeed- MedicineToday 2013; 14(4): 67-68 ing six months previously. Sally recalls that about two years ago, before she conceived her second child, she was quite sick with an ‘ovarian infection’ and then an ectopic pregnancy. Sally’s pelvic ultrasound results are normal, as are the results of urine and blood tests, including a full blood count, erythrocyte sedimentation rate, C-reactive protein level, thyroid function and serum prolactin level. Her serum follicle-stimulating hormone and other reproductive hormone levels are in the normal range for the luteal phase of the menstrual cycle. Professor Eden is Associate Professor of Reproductive Endocrinology at the What could be causing Sally’s night sweats? University of New South Wales; Director of the Barbara Gross Research Unit at the Royal Hospital for Women and the University of New South Wales; COMMENTARY Director of the Women’s Health and Research Institute of Australia; and Hot flushes and sweats are not unusual in women who are having Director of the Sydney MenopauseCopyright _LayoutCentre and 1 Medical 17/01/12 Co-Director 1:43 PM of Pagethe 4 regular menstrual cycles, especially during the bleeding phase © ISTOCKPHOTO/LISA VALDER.
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Fullness, and Tinni- Tus
Neurology® Clinical Practice The evaluation of a patient with dizziness Kevin A. Kerber, MD Robert W. Baloh, MD Summary Dizziness is the quintessential symptom presenta- tion in all of clinical medicine. It can stem from a disturbance in nearly any system of the body. Pa- tient descriptions of the symptom are often vague and inconsistent, so careful probing is essential. The physical examination is performed by observ- ing the patient at rest and following simple move- ments or bedside tests. In general, no special tools are required. The causes of dizziness range from benign to life-threatening disorders, and features that distinguish among these may be subtle. When diagnostic testing is considered, parsimony should be the rule. Identifying common peripheral vestibu- lar disorders is a priority. Picking this “low hanging fruit” can be the key component to excluding more serious central causes of dizziness. eurologists play an important role in the evaluation and management of pa- tients with dizziness. The possibility of a serious neurologic disorder is un- Nnerving to front-line physicians who have ranked decision support for identifying central causes of vertigo as a top priority.1 Although dangerous cen- tral disorders do not commonly present as isolated dizziness, stroke and other neurologic disorders can occur in this manner. The history and physical examination are the critical elements in determining the management of these patients. In this article, we review the approach to the evaluation and management of patients with dizziness. History The first step in assessing a patient presenting with dizziness is to define the symptom (table 1).
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Vertebral Artery Dissection Presenting As Transient Global Amnesia: a Case Report and Review of Literature
Dementia and Neurocognitive Disorders 2014; 13: 46-49 CASE REPORT http://dx.doi.org/10.12779/dnd.2014.13.2.46 Vertebral Artery Dissection Presenting as Transient Global Amnesia: A Case Report and Review of Literature , Yeonsil Moon*, Seol-Heui Han* † Vertebral artery dissection is one of the most common causes of stroke in young adults. The course of the vertebral artery dissection is usually benign, and pure transient amnesia as an initial symptom has Department of Neurology*, Konkuk University Medical Center, Seoul; Center for Geriatric been rarely reported. We describe a patient with vertebral artery dissection who presented with acute Neuroscience Research, Institute of transient amnesia, and review the medical literatures about the pathophysiological mechanism of tran- Biomedical Science†, Konkuk University, sient global amenesia (TGA). This case could be a one of evidence which supports the cerebrovascular Seoul, Korea mechanism of TGA. Received: May 19, 2014 Revision received: June 26, 2014 Accepted: June 26, 2014 Address for correspondence Seol-Heui Han, M.D. Department of Neurology, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea Tel: +82-2-2030-7561 Fax: +82-2-2030-7469 E-mail: [email protected] Key Words: Transient global amnesia, Vertebral artery dissection, Cerebrovascular Vertebral artery dissection is one of the most common longed cognitive decline and review the medical literatures causes of stroke in young adults [1]. The course of the verte- about the pathophysiological mechanism of transient global bral artery dissection is usually benign, but seldom reaches to amenesia (TGA). severe complication, such as brainstem infarction, subarach- noid hemorrhage (SAH) or death [2].
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Concurrent Beau Lines, Onychomadesis, and Retronychia Following Scurvy
CASE REPORT Concurrent Beau Lines, Onychomadesis, and Retronychia Following Scurvy Dayoung Ko, BS; Shari R. Lipner, MD, PhD the proximal nail plate from the distal nail plate leading to shedding of the nail. It occurs due to a complete growth PRACTICE POINTS arrest in the nail matrix and is thought to be on a con- • Beau lines, onychomadesis, and retronychia are nail tinuum with Beau lines. The etiologies of these 2 condi- conditions with distinct clinical findings. tions overlap and include trauma, inflammatory diseases, • Beau lines and onychomadesis may be seen 1-5 concurrently following trauma, inflammatory dis- systemic illnesses, hereditary conditions, and infections. eases, systemic illnesses, hereditary conditions, In almost all cases of both conditions, normal nail plate and infections. production ensues upon identification and removal of the 3,4,6 • Retronychia shares a common pathophysiology inciting agent or recuperation from the causal illness. with Beau lines and onychomadesis, and all reflect Beau lines will move distally as the nail grows out and slowing or cessation of nail plate production. can be clipped. In onychomadesis, the affected nails will be shed with time. Resolution of these nail defects can be estimated from average nail growth rates (1 mm/mo for fingernails and 2–3 mm/mo for toenails).7 Beau lines, onychomadesis, and retronychia are nail conditions with Retronychia is defined as a proximal ingrowing of their own characteristic clinical findings. It has been hypothesized the nail plate into the ventral surface of the proximal nail that these 3 disorders may share a common pathophysiologic fold.4,6 It is thought to occur via vertical progression of mechanism of slowing and/or halting nail plate production at the the nail plate into the proximal nail fold, repetitive nail nail matrix.
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Second Edition
COVID-19 Evidence Update COVID-19 Update from SAHMRI, Health Translation SA and the Commission on Excellence and Innovation in Health Updated 4 May 2020 – 2nd Edition “What is the prevalence, positive predictive value, negative predictive value, sensitivity and specificity of anosmia in the diagnosis of COVID-19?” Executive Summary There is widespread reporting of a potential link between anosmia (loss of smell) and ageusia (loss of taste) and SARS-COV-2 infection, as an early sign and with sudden onset predominantly without nasal obstruction. There are calls for anosmia and ageusia to be recognised as symptoms for COVID-19. Since the 1st edition of this briefing (25 March 2020), there has been a significant expansion of literature on this topic, including 3 systematic reviews. Predictive value: The reported prevalence of anosmia/hyposmia and ageusia/hypogeusia in SARS-COV-2 positive patients are in the order of 36-68% and 33-71% respectively. There are reports of anosmia as the first symptom in some patients. Estimates from one study for hyposmia and hypogeusia: • Positive likelihood ratios: 4.5 and 5.8 • Sensitivity: 46% and 62% • Specificity: 90% and 89% The US Centres for Disease Control and Prevention (CDC) has added new loss or taste or smell to its list of recognised symptoms for SARS-COV-2 infection. To date, the World Health Organization has not. Conclusion: There is sufficient evidence to warrant adding loss of taste and smell to the list of symptoms for COVID-19 and promoting this information to the public. Context • Early detection of COVID-19 is key to the ongoing management of the pandemic.
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Medical Terminology Abbreviations Medical Terminology Abbreviations
34 MEDICAL TERMINOLOGY ABBREVIATIONS MEDICAL TERMINOLOGY ABBREVIATIONS The following list contains some of the most common abbreviations found in medical records. Please note that in medical terminology, the capitalization of letters bears significance as to the meaning of certain terms, and is often used to distinguish terms with similar acronyms. @—at A & P—anatomy and physiology ab—abortion abd—abdominal ABG—arterial blood gas a.c.—before meals ac & cl—acetest and clinitest ACLS—advanced cardiac life support AD—right ear ADL—activities of daily living ad lib—as desired adm—admission afeb—afebrile, no fever AFB—acid-fast bacillus AKA—above the knee alb—albumin alt dieb—alternate days (every other day) am—morning AMA—against medical advice amal—amalgam amb—ambulate, walk AMI—acute myocardial infarction amt—amount ANS—automatic nervous system ant—anterior AOx3—alert and oriented to person, time, and place Ap—apical AP—apical pulse approx—approximately aq—aqueous ARDS—acute respiratory distress syndrome AS—left ear ASA—aspirin asap (ASAP)—as soon as possible as tol—as tolerated ATD—admission, transfer, discharge AU—both ears Ax—axillary BE—barium enema bid—twice a day bil, bilateral—both sides BK—below knee BKA—below the knee amputation bl—blood bl wk—blood work BLS—basic life support BM—bowel movement BOW—bag of waters B/P—blood pressure bpm—beats per minute BR—bed rest MEDICAL TERMINOLOGY ABBREVIATIONS 35 BRP—bathroom privileges BS—breath sounds BSI—body substance isolation BSO—bilateral salpingo-oophorectomy BUN—blood, urea, nitrogen
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Review of Systems
code: GF004 REVIEW OF SYSTEMS First Name Middle Name / MI Last Name Check the box if you are currently experiencing any of the following : General Skin Respiratory Arthritis/Rheumatism Abnormal Pigmentation Any Lung Troubles Back Pain (recurrent) Boils Asthma or Wheezing Bone Fracture Brittle Nails Bronchitis Cancer Dry Skin Chronic or Frequent Cough Diabetes Eczema Difficulty Breathing Foot Pain Frequent infections Pleurisy or Pneumonia Gout Hair/Nail changes Spitting up Blood Headaches/Migraines Hives Trouble Breathing Joint Injury Itching URI (Cold) Now Memory Loss Jaundice None Muscle Weakness Psoriasis Numbness/Tingling Rash Obesity Skin Disease Osteoporosis None Rheumatic Fever Weight Gain/Loss None Cardiovascular Gastrointestinal Eyes - Ears - Nose - Throat/Mouth Awakening in the night smothering Abdominal Pain Blurring Chest Pain or Angina Appetite Changes Double Vision Congestive Heart Failure Black Stools Eye Disease or Injury Cyanosis (blue skin) Bleeding with Bowel Movements Eye Pain/Discharge Difficulty walking two blocks Blood in Vomit Glasses Edema/Swelling of Hands, Feet or Ankles Chrohn’s Disease/Colitis Glaucoma Heart Attacks Constipation Itchy Eyes Heart Murmur Cramping or pain in the Abdomen Vision changes Heart Trouble Difficulty Swallowing Ear Disease High Blood Pressure Diverticulosis Ear Infections Irregular Heartbeat Frequent Diarrhea Ears ringing Pain in legs Gallbladder Disease Hearing problems Palpitations Gas/Bloating Impaired Hearing Poor Circulation Heartburn or Indigestion Chronic Sinus Trouble Shortness
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Review of Systems – Return Visit Have You Had Any Problems Related to the Following Symptoms in the Past Month? Circle Yes Or No
REVIEW OF SYSTEMS – RETURN VISIT HAVE YOU HAD ANY PROBLEMS RELATED TO THE FOLLOWING SYMPTOMS IN THE PAST MONTH? CIRCLE YES OR NO Today’s Date: ______________ Name: _______________________________ Date of Birth: __________________ GENERAL GENITOURINARY Fatigue Y N Blood in Urine Y N Fever / Chills Y N Menstrual Irregularity Y N Night Sweats Y N Painful Menstrual Cycle Y N Weight Gain Y N Vaginal Discharge Y N Weight Loss Y N Vaginal Dryness Y N EYES Vaginal Itching Y N Vision Changes Y N Painful Sex Y N EAR, NOSE, & THROAT SKIN Hearing Loss Y N Hair Loss Y N Runny Nose Y N New Skin Lesions Y N Ringing in Ears Y N Rash Y N Sinus Problem Y N Pigmentation Change Y N Sore Throat Y N NEUROLOGIC BREAST Headache Y N Breast Lump Y N Muscular Weakness Y N Tenderness Y N Tingling or Numbness Y N Nipple Discharge Y N Memory Difficulties Y N CARDIOVASCULAR MUSCULOSKELETAL Chest Pain Y N Back Pain Y N Swelling in Legs Y N Limitation of Motion Y N Palpitations Y N Joint Pain Y N Fainting Y N Muscle Pain Y N Irregular Heart Beat Y N ENDOCRINE RESPIRATORY Cold Intolerance Y N Cough Y N Heat Intolerance Y N Shortness of Breath Y N Excessive Thirst Y N Post Nasal Drip Y N Excessive Amount of Urine Y N Wheezing Y N PSYCHOLOGY GASTROINTESTINAL Difficulty Sleeping Y N Abdominal Pain Y N Depression Y N Constipation Y N Anxiety Y N Diarrhea Y N Suicidal Thoughts Y N Hemorrhoids Y N HEMATOLOGIC / LYMPHATIC Nausea Y N Easy Bruising Y N Vomiting Y N Easy Bleeding Y N GENITOURINARY Swollen Lymph Glands Y N Burning with Urination Y N ALLERGY / IMMUNOLOGY Urinary
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Anorexia/Cachexia Heart Failure Symptom Management Guideline for Adults, Age 19 and Older in British Columbia
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Fever / Sepsis
Fever / Sepsis History Signs and Symptoms Differential · Age · Warm · Infections / Sepsis · Duration of fever · Flushed · Cancer / Tumors / Lymphomas · Severity of fever · Sweaty · Medication or drug reaction · Past medical history · Chills/Rigors · Connective tissue disease · Medications Associated Symptoms · Arthritis · Immunocompromised (transplant, (Helpful to localize source) · Vasculitis HIV, diabetes, cancer) · myalgias, cough, chest pain, · Hyperthyroidism · Environmental exposure headache, dysuria, abdominal pain, · Heat Stroke · Last acetaminophen or ibuprofen mental status changes, rash · Meningitis Adult Contact, Droplet, and Airborne Precautions Temperature Measurement Procedure B / if available Pediatric General Section Protocols IV Procedure IO Procedure I P If indicated If indicated Temperature NO Greater than 100.4 F YES (38 C) If Suspected infection ? B then proceed to Protocol 72A otherwise Proceed to Protocol Exit to 72A Appropriate Protocol Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. · Patients with a history of liver failure should not receive acetaminophen. · Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions. · Airborne precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g.
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Chest Pain/Angina Humanresearchwiki Chest Pain/Angina
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Truncal Rashes Stan L
Healthy Baby Practical advice for treating newborns and toddlers. Getting Truculent with Truncal Rashes Stan L. Block, MD, FAAP A B C All images courtesy of Stan L. Block, MD, FAAP. Figure 1. Afebrile 22-month-old white male presents to your office with this slowly spreading, somewhat generalized, and refractory truncal rash for the past 4 weeks. It initially started on the right side of his trunk (A) and later extended down his right upper thigh (B). The rash has now spread to the contralateral side on his back (C), and is most confluent and thickest over his right lateral ribs. n a daily basis, we pediatricians would not be readily able to identify this rash initially began on the right side of his encounter a multitude of rashes relatively newly described truncal rash trunk (see Figure 1A) and then extended O of varied appearance in children shown in some of the following cases. distally down to his right upper thigh (see of all ages. Most of us gently-seasoned As is typical, certain clues are critical, Figure 1B). Although the rash is now dis- clinicians have seen nearly all versions including the child’s age, the duration tributed over most of his back (see Figure of these “typical” rashes. Yet, I venture and the distribution of the rash. Several 1C), it is most confluent and most dense to guess that many practitioners, who of these rashes notably mimic more com- over his right lateral ribs. would be in good company with some of mon etiologies, as discussed in some of From Figure 1, you could speculate my quite erudite partners (whom I asked), the following cases.
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