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Review of Systems (ROS) Checklist Layman's Terms MBLD Session 1

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Review of Systems (ROS) Checklist Layman's Terms MBLD Session 1 Review of Systems (ROS) Checklist Layman's Terms MBLD Session 1 General fever Mouth change in taste chills pain in mouth or tongue sweats bleeding gums night sweats lesions in mouth or gums weight change (up or down) lesions on lips or tongue overall health Throat sore throats Skin lesions hoarseness rashes painful swallowing itching Chest coughing up blood sores phlegm change in hair or nails cough change: in moisture shortness of breath (SOB) temperature wheezing color sharp CP with deep breath or cough texture Cardiac chest pain (CP) Heme large or rapid, strong or tender lymph nodes/glands irregular heartbeat excessive bleeding or light-headedness bruising passing out history of (h/o) anemia swelling in feet Head headaches history of (h/o) heart murmur head injury h/o blood clots Eyes glasses/contacts calf pain at rest eye pain calf pain with exercise redness SOB with exertion discharge sudden awakening w/ SOB infection SOB while lying flat (# pillows) injury change in activity tolerance flashes of light Breasts pain or lumps double vision discharge blurring GI changes in appetite loss of vision gastrointestinal heartburn Ears hearing loss reflux ringing in the ears abdominal pain pain hernias infection fullness discharge distention sensation of room spinning vomiting blood Nose change or vomiting coffee ground material loss of sense of smell nausea discharge vomiting obstruction yellowing of the skin or eyes sinus pain recent changes in bowel habits: nose bleeds pain with bowel movement (BM) Blue Font: you don't need to Begin with the word 'Any' to say out loud the title of the system avoid asking a leading questions Majority NEED to be recited in PAIRS Review of Systems (ROS) Checklist Layman's Terms MBLD Session 1 GI cont going more or less often Endo cont sensitivity to heat or cold diarrhea increased thirst constipation change in size of: hands black or feet maroon colored stools facial features hemorrhoids neck blood in stools problems w/ thyroid other change in consistency or color Muscles & pain or tenderness in muscles or joints Urinary pain with urination Bones stiffness urinating often w/ little volume swelling compelling urge to urinate past injury or deformity leaking urine limited movement of the: neck urinating increased amounts trunk urinating decreased amounts extremities unable to urinate Nervous seizures difficulty initiating stream System difficulty speaking urinating at night, (#) difficulty swallowing blood in urine tremor foamy urine weakness tenderness back/flank numbness or tingling h/o bladder/ kidney infections burning or shooting pain stones abnormal clumsiness Genital gential lesions difficulty w/ balance rashes difficulty w/ bowel pain difficulty w/ bladder control discharge (penile/vaginal) Mental change in moods painful intercourse Health prolonged crying Women what age did your period start? confusion still menstruating? difficulty thinking menopause, age memory loss Are peroids monthly? phobias How heavy are they? hallucinations 1st day of last menstrual period agitation Men testicular pain previous treatment of psychiatric or emotional illness testicular lumps Total 162 points problems w/ erections 152 > correct to pass problems w/ ejaculations in PAIRS when it make sense Endo easy fatigue in 5 minutes 7/23-24 sleep distrubances in 5 minutes 7/30-31 behavioral changes in 5 minutes 8/6-7 Blue Font: you don't need to Begin with the word 'Any' to say out loud the title of the system avoid asking a leading questions Majority NEED to be recited in PAIRS ROS Checklist Medical Vernacular MBLD Session 3 1 2 3 General diaphoresis Skin pruritus Heme lymphadenopathy ecchymosis Eyes diplopia Ears acuity tinnitus vertigo Nose anosmia epistaxis Pharynx/ larynx pharyngitis odynophagia Respiratory dyspnea pleuritic CP Cardiovascular palpitations presyncope or near syncope syncope DVTs: deep venous thrombosis claudication dyspnea on exertion (DOE) orthopnea paroxysmal nocturnal dyspnea (PND) GI reflux/GERD melena hematemesis coffee-ground emesis icterus hematochezia GU dysuria polyuria oliguria nocturia, # hematuria nephrolithiasis Genital dyspareunia Female/GYN menarche Endo polydipsia Neuro dysarthria dysphagia paresthesias neuropathic pain Total ROS Checklist: MUST BE ASKED IN PAIRS (ask no more FON than ROS 2Checklist items at a time) General: Any fever or chills? Sweats or night sweats?Layman's Weight change Terms (up or down)? How is your overall health? Skin: Any lesions or rashes? Itching or sores? Change in hair or nails? Change in moisture or temperature of skin? Color or texture of the skin? Hematologic: Any large or tender lymph nodes? Excessive bleeding or bruising? History of anemia? Head: Any headaches or head injury? Eyes: Any glasses or contacts? Eye pain? Redness or discharge? Infection or injury? Flashes of light or double vision? Blurring or loss of vision? Ears: Any hearing loss or ringing in the ears? Any pain or infection? Discharge or sensation of the room spinning? Nose: Any change or loss of the sense of smell? Discharge or obstruction? Sinus pain or nose bleeds? Mouth: Any change in taste? Pain in mouth or tongue? Bleeding gums? Lesions of the mouth or gums? Lesions of the lips or tongue? Throat: Any sore throat or hoarseness? Painful swallowing? Chest: Any coughing up blood or phlegm? Cough? SOB or wheezing? Sharp chest pain with deep breath or cough? Cardiac: Any chest pain? Rapid or strong heartbeat? Irregular heartbeat? Light-headedness or passing out? Swelling in the feet? History of heart murmurs or blood clots? Calf pain with rest or exercise? SOB with exertion? Sudden awakening with SOB? SOB with lying flat (if yes, how many pillows needed to sleep)? Change in activity tolerance? Breasts: Any pain or lumps? Discharge? Gastrointestinal: Any change in appetite? Heartburn or reflux? Abdominal pain or hernia? Fullness or distension? Vomiting blood or coffee ground material? Nausea or vomiting? Yellowing of skin or eyes? Recent changes in bowel habits? Pain with bowel movements? Going more or less often? Diarrhea or constipation? Black or maroon colored stools? Hemorrhoids or blood in stool? Other change in consistency or color? Urinary: Any pain with urination? Urinating often with little volume? Compelling urges to urinate or leaking urine? Urinating increased or decreased amounts? Unable to urinate or difficulty initiating the stream? Urinating at night (#)? Blood in the urine or foamy urine? Tenderness in the back or flank? History of bladder or kidney infections? Kidney stones? Genital: Genital lesions or rashes? Pain or discharge? Painful intercourse? *Women: What age did you start your period? Are you still menstruating? If no: Have you gone through menopause (age)? If yes: are your periods monthly? How heavy are they? When was the first day of your last menstrual period (date)? Or *Men: Any testicular pain or lumps? Problems with erections or ejaculation? Endocrine: Any easy fatigue or sleep disturbances? Behavioral changes? Sensitivity to heat or cold? Increased thirst? Change in size of hands or feet? Facial features or neck? Problems with thyroid? Muscles and Bones: Any pain or tenderness in muscles or joints? Stiffness or swelling? Past injury or deformity? Limited movement of the neck or trunk? Or extremities? Nervous System: Any seizures? Difficulty speaking or swallowing? Tremor or weakness? Numbness or tingling? Burning or shooting pain? Abnormal clumsiness or difficulty with balance? Difficulty with bowel or bladder control? Mental Health: Any change in moods or prolonged crying? Confusion or difficulty thinking? Memory loss or phobias? Hallucinations or agitation? Previous treatment of a psychiatric or emotional illness? SOAP ROS Checklist Medical Vernacular ROS Checklist Gen: No fever, chills, diaphoresis, night sweats, or weight change. Good overall health. Skin: No lesions, rashes, pruritus, sores, or change in hair or nails. No change in moisture, temperature, color, or texture of the skin. Heme: No lymphadenopathy, excessive bleeding, bruising (or ecchymosis), or h/o anemia. Head: No headaches or head injury. Eyes: No glasses/contacts. No eye pain, inflammation, D/C, infection, injury, flashes of light, diplopia, blurring or loss of vision. Ears: No decrease in acuity. No tinnitus, pain, infection, D/C or vertigo. Nose: No change in sense of smell or anosmia. No D/C, obstruction, sinus pain, epistaxis. Mouth: No change in taste or pain in mouth/tongue. No bleeding gums. No lesions on the mouth, gums, lips, or tongue. Pharynx/ larynx: No pharyngitis, hoarseness, or odynophagia. Chest: No sputum, hemoptysis, sputum, cough, dyspnea, wheezing, or pleuritic CP. CV: No CP, palpitations, light-headedness/pre-syncope, syncope, or edema. No h/o heart murmurs, DVTs, claudication, DOE, PND, orthopnea, or change in activity tolerance. Breasts: No pain, mass, or d/c. GI: No change in appetite, heartburn, reflux/GERD, fullness/distension, or pain. No nausea, vomiting, hematemesis, or coffee-ground emesis. No hernia, jaundice/icterus, pain with BM, recent changes in frequency/consistency/color of BM, melena, diarrhea, constipation, hemorrhoids, or hematochezia. GU: No dysuria, frequency, urgency, polyuria, oliguria, retention, hesitancy, nocturia (#), incontinence, hematuria, foamy urine, flank/CVA tenderness, UTI, or nephrolithiasis. Genital: No genital lesions, rashes, pain, D/C or dyspareunia. GYN: Menarche: age ___ Menopause: age ___ or N/A. Menses occurs monthly: Y/N. Menstrual flow: light, moderate/normal, heavy. LMP ___. Or *Male: No testicular lumps or
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