ROS

General

General

weight gain or weight loss, changes in appetite, weakness, fatigue, fever, chills, night sweats

skin

rashes, pruritus (itching), bruising, dryness, color changes, suspicious lesions, skin cancer, hair or nail changes, tattoos or piercings

Head

trauma, lumps, growth, pain, hair loss

eyes

do you wear contact lenses, last eye exam, photophobia (light sensitivity), blurred vision, diplopia (double vision), scotomata (blind spot), floaters, flashing lights, halos around lights, pain redness, discharge, dry eyes, excessive tearing, cataract hx, glaucoma hx, infection or sudden loss of vision

ears

hearing changes, tinnitus (ringing/buzzing), pain, discharge, ear infection

nose and sinuses

epistaxis (nose bleed), nasal trauma, discharge, allergies, polyps, obstruction, excessive snoring, sinus infections, loss or change in smell

oral cavity

teeth / dentures / bridge problems, last dental checkup, gum disease (bleeding or sore), tongue / mucosa issues (sore, lesions, ulcers), voice hoarseness / changes, oral pain

neck

goiter (thyroid mass), swollen glands, tenderness, pain, reduced range of motion

breasts

lumps, discharge, tenderness, self examination, mammogram history, family history of breast cancer

respiratory

cough, sputum (color and amount), hemoptysis (blood coughed up from lungs, not just streaks), dyspnea, wheezing, SOB (rest and exertion), history of pneumonia, bronchitis, influenza, asthma, emphysema, COPD, TB exposure / positive PPD, inhalant exposure, last chest xray

cardiovascular

history of MI, chest discomforts, palpitations, exertional dyspnea, orthopnea (supine SOB), PND (paroxysmal nocturnal dyspnea- SOB that wakes you up), rheumatic fever, HTN, peripheral edema, murmurs, last EKG, stress test, echocardiogram

gastrointestinal

changes in appetite, dysphagia (trouble swallowing), dyspepsia (heartburn), nausea, vomiting, hematemesis (vomiting blood), abdominal pain, peptic ulcer disease PUD, diarrhea, constipation, flatulence, excessive borborygmi, polyps, hemorrhoids, rectal bleeding, changes in stool shape color frequency, liver disease, jaundice, food intolerance, frequent belching or gas, gallstones, last colonoscopy

genitourinary

frequency, urgency, nocturia, hesitancy, weakened urinary stream, dysuria (pain/burning), hematuria, incontinence, infections, lesions, discharge, changes in odor or color, kidney stones, kidney disease, hernias

male genitals

testicular / scrotal masses, prostate disease, last PSA (prostate specific antigen), last DRE (digital rectal exam), erectile dysfunction

gynecologic

menarche, last menstrual period LMP, dysmenorrhea, spotting or bleeding, menopause, dyspareunia (painful intercourse), pregnancies (gravida), live deliveries (para), premature deliveries, early birth terminations (miscarriages / spontaneous or abortion), exposure from maternal use of DES during pregnancy before 1971

sexual history

sexually active, number of partners, sexual orientation, satisfaction, STD, HIV, contraception use, sexual abuse, libido changes, fertility issues

peripheral vascular

intermitten claudication (waking pain in leg, hip, calf), cramps, edema (arms/legs), varicose veins, temperature changes (feet/hands/toes/fingers), thrombophlebitis, loss of hair, ulcerations, skin thickness changesm

musculoskeletal

pain (muscle, bone, joint), trauma, redness, tenderness, swelling, stiffness, cramping, arthritis, gout, backaches, limited ROM, scoliosis, fractures

neurologic

headaches, syncope, dizziness, vertigo (hallucination of movement), loss of consciousness LOC, ataxia (balance/coordination issues), seizure, weakness, paresthesia (pins and needles), CVA/TIA (stroke), paralysis, tremors, involuntary movements

endocrine

polyuria, polydipsia, polyphagia, temperature intolerance, diabetes, hormone therapy, hair changes, skin texture, excess sweating, glove / shoes size change, thyroid disorder

hematologic

anemia, bleeding tendency, easy bruising, lymphadenopathy, blood clot, blood transfusion and if so reactions

psychiatric

anxiety, nervousness, mood changes, panic attacks, PTSD, phobias, depression, memory change or loss, sleep disturbances, loss of energy, decreased concentration, suicidal ideation or attempts, schizophrenia, psychosis, family psych history, hallucinations, drug/alcohol abuse, unexplained physical complaints, victims of abuse, psychiatric / counseling treatment

past medical history

childhood illnesses, pertinent adult medical chronic illnesses (DM, HTN, cancer, COPD), past hospitalizations, surgeries

health maintenance

immunizations, health screenings (pap/PSA), medications (names, strengths, dosages, frequency, how taken), OTC medications or herbal supplements, medication allergies and reaction, environmental/food allergies and reaction

family history

at least 3 generations

personal/social/sexual

living arrangement, marital status, children, DV, sexual partners, men, women, or both, STDs, occupation, highest degree/educations, stressors, ADLs, exercise, leisure activity, diet, caffeine intake, safety measures (bike helmet, seat belts, smoke detectors), tobacco use, alcohol use, illicit drug use, spiritual/religious preferences with treament

order for oral case

CC, HPI, ROS, summarize to patient, PMH, FH, SH, DDX

headache case ddx

migraine attack POUND, tension headache, cluster headache

headache case other ddx

giant cell arteritis GCA, TMJ syndrome, intracranial mass, meningitis, subarachnoid hemorrhage

cough case ddx

acute bronchitis, asthma, pneumonia

cough case other ddx

post nasal drip syndrome, CHF, COPD, GERD, hypersensitivity pneumonitis

sore throat case ddx

acute strep pharyngitis, viral upper respiratory infection, infectious mononucleosis

sore throat other ddx

tonsillitis, post nasal drip syndrome, HIV, HSV, STDs, pharyngeal abscess

ear pain case ddx

acute otitis media, acute otitis externa, barotrauma

ear pain other ddx

Eustachian tube dysfunction, perforated TM, bullies myringitis, cerumen impaction, mastoiditis

dyspepsia case ddx

GERD exacerbation, peptic ulcer disease PUD, hiatal hernia

dyspepsia case other ddx

IBS, chest pain/cardiac mimicker, pancreatitis

dysuria case ddx

UTI, cystitis, pyelonephritis

dysuria other ddx

vaginitis, STDs, interstitial nephritis, urinary tract obstruction, kidney stone