Help Assessment Final

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http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/9780781767187_Bickley/sampleChapter1.pdf

A review of systems (also called a systems enquiry) is a technique used by health-care providers for eliciting a history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). It can be particularly useful in identifying conditions that don't have precise diagnostic tests.

Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. Different sources describe slightly different systems of organizing the organ systems. However, the following are examples of what can be included:

There are 14 systems recognized by the CMS:

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[TD]Constitutional symptoms (e.g., fever, weight loss)

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[TD]unexplained weight loss, night sweats, fatigue/malaise/lethargy, sleeping pattern, appetite, fever, itch/rash, recent trauma, lumps/bumps/masses, unexplained falls

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[TD]Eyes

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[TD]visual changes, headache, eye pain, double vision, scotomas (blind spots), floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs amaurosis fugax)

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[TD]Ears, nose, mouth, and throat (ENT)

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[TD]Runny nose, frequent nose bleeds (epistaxis), sinus pain, stuffy ears, ear pain, ringing in ears (tinnitus), gingival bleeding, toothache, sore throat, pain with swallowing (odynophagia)

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[TD]Cardiovascular

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[TD]chest pain, shortness of breath, exercise intolerance, PND, orthopnoea, oedema, palpitations, faintness, loss of consciousness, claudication

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[TD]Respiratory

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[TD]cough, sputum, wheeze, haemoptysis, shortness of breath, exercise intolerance

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[TD]Gastrointestinal

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[TD]abdominal pain, unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion, bloating, cramping, anorexia, food avoidance, nausea/vomiting, diarrhea/constipation, inability to pass gas (obstipation), vomiting blood (haematemesis), bright red blood per rectum (BRBPR, hematochezia), foul smelling dark black tarry stools (melaena), dry heaves of the bowels (tenesmus)

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[TD]Genitourinary

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[TD]Urinary: Irritative vs Obstructive symptoms: Micturition - incontinence, dysuria, haematuria, nocturia, polyuria, hesitancy, terminal dribbling, decreased force of stream

Genital: lady partsl - discharge, pain, Menses - frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus, menarche, menopause, contraception (if relevant), date of last smear test and result

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[TD]Musculoskeletal

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[TD]pain, misalignment, stiffness (morning vs day long; improves/worsens with activity), joint swelling, decreased range of motion, crepitus, functional deficit, arthritis

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[TD]Integumentary

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[TD]pruritus, rashes, stria, lesions, wounds, incisions, acanthosis nigricans, nodules, tumors, eczema, excessive dryness and/or discoloration.

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[TD]Neurological

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[TD]Special senses - any changes in sight, smell, hearing and taste, seizures, faints, fits, funny turns, headache, pins and needles (paraesthesiae) or numbness, limb weakness, poor balance, speech problems, sphincter disturbance, higher mental function and psychiatric symptoms

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[TD]Psychiatric

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[TD]depression, sleep patterns, anxiety, difficult concentrating, body image, work and school performance, paranoia, ahedonia, lack of energy, episodes of mania, episodic change in personality, expansive personality, sexual or financial 'binges',

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[TD]Endocrine

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[TD]Hyperthyroid: prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite, tremor, palpitations, visual disturbances;

Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation, dry skin

Diabetes: polydipsia, polyuria, polyphagia (constant hunger without weight gain is more typical for a type I diabetic than type II), symptoms of hypoglycemia such as dizziness, sweating, headache,hunger, tongue dysarticulation

Adrenal: difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed places

Reproductive (female): menarche, cycle duration and frequency, lady partsl bleeding irregularities, use of birth control pills

Reproductive (male): difficulty with erection or sexual arousal, depression, lack of stamina/energy

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[TD]Hematologic/lymphatic

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[TD]anemia, purpura, petechia, results from routine hemolytic diseases screening, prolonged or excessive bleeding after dental extraction / injury, use of anticoagulant and antiplatelet drugs (including aspirin), family history of hemophilia, history of a blood transfusion, refused for blood donation

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[TD]Allergic/immunologic

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[TD]"Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.

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The questions may be asked of the patient in a "head to toe" manner. I am usually not a wiki fan but this is good. Review of systems - Wikipedia, the free encyclopedia

History and Physical Admit Orders Advice Help Tips Secrets another good source.

GOOD! Good luck!