review of systems nursing example

Adult Review of Systems (ROS)

• As a screening tool asked of every patient that the clinician encounters.
• Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to uncover occult disease of the prostate to men over 50; or using a cardiovascular ROS in patients who have cardiovascular risk factors).
• The questions asked reflect an array of common and important clinical conditions
• These disorders would go unrecognized if the patient was not specifically prompted
• The identification of these conditions then has a positive impact on morbidity/mortality

Unfortunately, aside from a few specific screening tools (e.g. depression), there is little evidence to support these assumptions. In fact, positive responses to a screening ROS are often of unclear significance, and may even create problems by generating a wave of additional questions (and testing) that can be of low yield. For these reasons, many clinicians (myself included) favor a more targeted/thoughtful application of ROS questions, based on patient specific characteristics (e.g. age, sex) and risk factors (e.g. history of diabetes → perform cardiovascular ROS). This strategy, I think, is both more efficient and revealing. As you gain experience, you can make an informed decision about how you'd like to incorporate the ROS into your overall patient care strategy.

It's important to recognize that positive responses will require follow-up questioning. For example, if a patient responds “yes” to an ROS question about chest pain, you would then need to ask additional questions to further define the core dimensions of this symptom. The OLD CARTS mnemonic (or other similar frameworks) provide structure for these follow-up questions. In addition, for a patient with chest pain, an assessment of cardiac risk factors and an organized search for exam findings indicative of vascular disease (e.g. elevated BP, diminished peripheral pulses, etc.) would be relevant. In addition to also consider non-cardiac etiologies (e.g. pulmonary, GI, MSK, etc.). On the basis of the sum of this data, the clinician can come to an informed conclusion about the importance/cause of this patient's chest pain (e.g. angina, heartburn, pulmonary embolism), and use this to guide their subsequent decision making.

Guide To Using This ROS

There is no ROS gold standard. The breadth of questions included is somewhat arbitrary, based on the author's sense of the most commonly occurring illnesses and their symptoms. There is planned redundancy, as the same symptoms often apply to multiple organ systems. Feel free to edit/adapt to fit your clinical needs. Realize that exotic or regional illnesses might require other ROS questions. In addition, some sub-specialty areas use an expanded ROS, specific to the conditions that they evaluate and treat.

• Clicking on the main questions reveals a list of common disorders that might be at the root cause of the particular symptom.
• Comments in parentheses that follow include other symptoms and/or historical features commonly linked to that particular disorder.
• "Red flag" indicates symptoms that are particularly worrisome for a serious illness.
• Where possible, I've bundled the diagnostic possibilities into clinically logical groupings (e.g. acute/chronic, painful/painless, upper/lower, etc.).
• The list of possible diagnoses that follows a question is not exhaustive. In addition please realize that no patient responses are pathognomonic.
• Common associated symptoms, risk factors, exam findings, and selected links to additional info are provided in (parentheses) after most items on the differential. This is only meant to point you in the right direction in terms of possible diagnoses – it is not meant to be inclusive.
• The disease categorizations reflect rough groupings. There are many exceptions. For example, disorders listed in the "acute" section may have chronic presentations, those described as "upper abdominal" may present w/thoracic symptoms, etc.

Clicking on the main categories reveals a list of broad questions. Clicking on any of these symptoms questions reveals a list of common disorders that might be at the root cause of the particular symptom.

More Info About General Symptoms: National Library of Medicine/Medline Plus

Comprehensive HPI and the rest of the history

• Appropriate → dieting
• Inappropriate → anorexia (chronic/progressive, hyper-concern about weight and body image, women>men, binge/purge cycles, hide eating habits)
• COPD (high work breathing, too sob to eat)
• CHF (high work breathing and activity, too sob to eat)
• Hyperthyroidism
• Malignancies → calories diverted to grown cancer, decreased appetite → cancer site defined by localizing symptoms
• Chronic infections - in particular TB and HIV
• Illicit drug use - in particular methamphetamines - focus of life and money soley on drug use
• Medications which affect appetite → chronic nausea, abdominal pain, diarrhea → chemo for cancer, HIV rx
• stroke (other vascular risk factors, problems w/initiating swallowing, other focal findings, hx aspiration)
• parkinsons disease ( resting tremor , bradykinesia, shuffling gait, cogwheel rigidity on exam)
• mechanical problems with chewing → dental problems (prevent chewing and/or cause pain)
• chronic inflammatory processes- HIV , Bechets
• mucositis from chemotherapy
• Cancer (Progressive swallowing problems → food gets stuck, worse w/solids then liquids, pain,> 50, chronic GERD, smoking, ETOH abuse)
• Zenker's diverticulum (chronic symptoms, bad breath, sensation food stuck in throat/upper esoph, regurgitation undigested food)
• esophageal web or ring (chronic, non-or slowly progressive, sensation of food getting stuck → occurring more w/larger solids )
• esophageal stricture (long hx gerd or hx caustic ingestion; sensation of food getting stuck → occurring more w/larger solids, can be progressive if related to chronic inflammatory process)
• candidiasis (often compromised host → cancer/chemo/hiv, evidence candida in mouth)
• HSV (oral hsv, often compromised host → cancer, chemo, hiv)
• pills (symptoms occur soon after incomplete swallowing of pill, patient can often point to spot along esophagus where pain is focused)
• achalasia (progressive dysphagia, solids and liquids, regurgitation, GERD, food sticks lower area esophagus)
• esophageal spasm (acute, intermittent pain and difficulty w/swallowing)
• eosinophilic esophagitis (allergies, asthma, no pain, no response to PPI)
• Chaga's disease (from central or south America, low socio-economic class, progressive)
• Scleroderma ( skin tightening , women > men, < 50, GERD, known disease)
• Cancer (feel full when eating ever small quantities of food., pain, > 50, smoking, ETOH abuse)
• pyloric stricture (history ulcer disease, hx past gastric surgery)
• extrinsic gastric compression for other abdominal mass e.g. profound splenomegaly
• gastroparesis from autonomic dysfxn (Hx DM w/poor control, early satiety, decreased sensation feet/other evidence DM induced neuropathy)
• chronic pancreatitis (hx multiple episodes prior pancreatitis from any etiology)
• IBD - Chron's Disease or UC (sub-acute, recurrent or chronic; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic Sx; presentation can also be fulminant)
• mesenteric ischemia (known atherosclerosis or risk factors, known risk factors for embolic disease → a fib, ventricular thrombus, acute low BP superimposed on atherosclerosis, persistent/progressive generalized pain w/few exam findings)
• parasites (sub-acute or chronic, watery → Giardia; bloody → Ameobiasis; camping/drinking unfiltered water)
• HIV (chronic and progressive, atypical infxns → parasite, fungal)
• bacterial overgrowth s/p gastric bypass
• IBD (sub-acute, recurrent or chronic; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic Sx; presentation can also be fulminant)
• celiac disease (bloating, gas, wt loss/inability to gain weight, chronic symptoms)
• chronic pancreatitis (multiple past episodes pancreatitis, ETOH abuse or other chronic exposure to pancreatitis inducing toxins/process, chronic upper abdominal pain, back pain, nausea, vomiting, bloating, stools difficult to flush)
• lactose intolerance (n, bloating, gas, abd discomfort → within few hours eating milk/milk products)
• Whipple's disease (rare d/o, chronic diarrhea, wt loss, abd pain, male>female, fatigue, joint pain)
• hyperthyroidism (irritability, inability to sleep, weight loss, palpitations, tremor, heat intolerance, diarrhea)
• laxative, sorbitol, use/abuse; excessive caffeine intake
• Other causes chronic diarrhea Diarrhea or other change in bowel habits
• anosmia (can't smell normally), which affects taste
• Chronic or acute kidney disease
• Chronic or acute liver disease
• Other chronic medical conditions
• Other - depression, psychiatric illness
• inactivity (no regular walking or exercise)
• hypothyroidism (wt gain, edema, dry skin, constipation, cold intolerance, depression)
• excessive caloric intake
• advanced kidney disease
• CHF (C/V RFs, orthopnea, PND, exam findings: lower extremity edema , + S3 , elevated jvp , displaced pmi , rales on lung exam )
• Ascites → GI Abdominal swelling or distention?
• obstructive sleep apnea (snoring, obese, observed apnea, poorly rested in AM, daytime fatigue)
• Travel/jet lag, work with odd hours/shifts
• Hypothyroidism (wt gain, edema, dry skin, constipation, cold intolerance, depression)
• Hypercalcemia (polyuria, constipation, confusion, Bone pain, known/suscepted squamous cell ca)
• Diabetes (known dz → poor control, polyuria, polydypsia)
• Low Testosterone (decreased libido, erectile dysfxn)
• Adrenal Insufficiency (poorly in general, n, v, orthostatic sx)
• Cancer - type identified based on detailed review major organ systems
• depression (little interest or pleasure in doing things; feeling down depressed or hopeless)
• substance abuse
• DJD (chronic pain, difficulty moving)
• Chronic or sub-acute inflammatory disorders - Rheumatoid Arthritis, Lupus, polymyalgia, other
• HIV (generalized sx → wt loss, fatigue; HIV RFs: men having sex w/men, sex w/prostitutes, IVDU, transfusion w/o screening, sexually active, past STI, TB, sex w/anyone w/HIV RFs, sex for money)
• TB (cough x weeks, hemoptysis, wt loss; immunocompromised → malnourished, chronic steroids, known HIV or HIV RFs, malnutrition; endemic area)
• Sub-acute: endocarditis
• COPD (SOB, DOE, sputum, acute or chronic, cough, smoking, wheezing)
• Other chronic pulmonary disorders
• Bradycardia (fatigue, decrease exercise tolerance, CHF Sx)
• polymyositis
• myasthenia gravis (subacute, progressive, worse w/repetitive movement)
• stroke (acute, focal deficits, vascular dz risk factors)
• multiple sclerosis (relapsing/remitting, patchy symptoms: numbness, visual changes, balance/coordination)
• guillain barre (acute, progressive, ascending pattern of involvement)
• CIDP (pain, tingling, numbness, focal weakness)
• ALS (progressive weakness, twitching, breathing problems)
• Parkinson's disease (older, progressive, rigidity, difficulty starting/stopping movement, balance problems, gait problems)
• Chronic liver disease
• chronic kidney disease
• profound hypokalemia
• hypercalcemia
• hyponatremia
• central sleep apnea
• hyperthyroidism (irritability, diarrhea, palpitations, tremor, heat intolerance)
• BPH --- See: GU -- Urination at Night?
• meds (nocturnal diuretics, caffeine)
• excessive intake PM liquids, ETOH
• diabetes (poorly controlled sugars)
• mental illness - depression, anxiety
• A possible non-specific indicator of problems
• Patients sometimes neglect to mention evaln/rx by other MDs/Clinics, ERs, hospitals, etc
• often underappreciated and under addressed

Bacteria Gram Negative Organisms e coli (GNR, cause uti, also abdominal/pelvic abscesses; HO157 causes enteritis and HUS) klebsiella, enterobacter, serratia (GNRs, cause of urinary tract infection, also abdominal/pelvic abscesses; hospitalized patients → pneumonia, wound infection, uti) proteus (common cause of urinary tract infection, can contribute to stone formation; wound infection hospitalized patients) pseudomonas (lung infections in patients with bonchiectasis → CF, COPD, compromised pts; bacteremia in patients w/neutropenia, also abdominal/pelvic abscesses, wound infection in patients w/DM; wound and urinary infections hospitalized/compromised pts; osteomyeliitis; otitis externa in patients w/DM) neisseria meningitidis (GNC, meningitis; f, c, ha, n, v, sepsis) neisseria gonorrhea (GNC, urethritis; cervicitis/PID; if disseminated infectious arthritis) moraxella (GNC, otitis media; bronchitis in copd exacerbation; pneumonia in COPD) legionella (community acquired pneumonia, cough, sputum, f, c) haemophilus influenza (pneumonia, otitis media, epiglottitis, meningitis; much less common since widespread use of vaccine) HACEK organisms (endocarditis → typically sub-acute → f, c, malaise x weeks) salmonella typhi (relapsing daily fever x weeks, malaise, ha, chills, relative brady, related to poor sanitation → outbreaks, travel to endemic areas, gall bladder can act as reservoir) non-tyhoidal (diarrhea, n, v, cramps, often w/bloody stools) shigella (diarrhea, n, v, cramps, often w/bloody stools, typically self limited) campylobacter (diarrhea, n, v, cramps, often w/bloody stools, typically self limited) yersinia enterocolitica (diarrhea, f, c, cramps; typically self limited) pestis → plague (passed from rodents to humans by fleas or direct contact w/feces, rapid onset f, c, sepsis, pneumonia) helicobacter (stomach ulcers) pertussis (characteristic whooping cough; kids can have airway compromise; adults presents as persistent cough x weeks easily spread; vax of kids and re-vax of adults preventive) Other less common gram negatives vibrio cholera (toxin mediated profound watery diarrhea, related to exposure to unclean water sources, often s/p natural disasters → presents as epidemics) vulnificus (causes sepsis in hosts w/cirrhosis or otherwise compromised hosts, exposure via raw/under cooked shellfish; also skin infection if same hosts exposed via inoculation) francisella tularensis → tularemia (passed from dying wild animals to humans via ticks/insects, US Southeast and Rocky Mtns, causes skin ulcers, lymphangitis, f, c) brucella (ingestion of raw/uncooked dairy, not present in all countries, causes recurrent f, c, systemic sx, arthritis, other organ involvement) batonella henslae (caused by cat scratch, regional adenopathy w/in few weeks, fatigue) bacillary angiomatosis ( nodules on skin , resemble Kaposis Sarcoma , occurs in HIV infected or otherwise compromised pts) Gram positive organisms Cocci Staph aureus coag + ( cellulitis , skin abscess ; wounds; osteomyelitis via direct extension; arthritis; bacteremia with seeding of abnormal or artificial valves, joints or devices; virulent w/rapid destruction valves/death w/in hours/days; toxic shock; pneumonia following viral infection; toxin based food poisoning → n/v hours after exposure, others affected who ate same) coag - ( cellulitis , skin abscess ; bacteremia with seeding of abnormal or artificial valves, joints or devices, less virulent than coag +) mrsa ( cellulitis , skin abscess ; bacteremia with seeding of abnormal or artificial valves, joints or devices, can be hospital or community acquired; healthcare assoc pna) Streptococcus Group A (cellulitis/lymphangitis; skin abscess; erysipelas; throat infections → acute pain, f, adenopathy: pharyngeal erythema and d/c; impetigo; contribues to necrotizing fasciitis ; scarlet fever → high temp, rash, palatal petchiae, throat sx) Group B (endometritis, meningitis, bacteremia, neonatal infection) Group D → enterococcus (urinary tract infection, pelvic/abd abscess, wound/other infxn in chronically ill/hospitalized patients) Viridans (endocarditis → subacute w/sx f, c, malaise x weeks) pneumoniae (pneumonia, upper respiratory infections, meningitis; bacteremia if severe; increased risk if s/p splenectomy) Rods listeria (meningitis in old and young patients) diptheria (upper respiratory infection w/cough, f, sore throat, pseudo-membrane w/airway obstruction; uncommon now w/vax) anthrax (acquired from animal exposure or biological weapon; inhalation: cough, f, c,pneuonia sepsis; cuteaneous: ulcer to eshcar w/surrounding edema) Anaerobes (GN or GP) often associated with mixed/complex infections/abscesses of abdomen, pelvis, lung, mouth clostridium: GPR perfringes (most common cause food born diarrhea → undercooked meat, cramps, diarrhea, 6-18h after ingestion, resolves in 24h, other who ate same ill simultaneously; deep tissue infection contibuting to necrotizing faciitis ; contribute to abd/pv abscess; NEC in neonates) difficile (antibiotic associated colitis, can occur after any abx, cramps, diarrhea) tetani (exposure via contaminated wounds if unvax, 1w incubation,increased tone in jaw muscles, dysphagia, diffuse musle pain/spasams, airway compromise; uncommon w/widespread use vax) botulinum (food/wound born toxin, incubation 1-2d, rapid descending symetric paralysis staring w/cranial nerves, dizziness, dry mouth, visual sx, no sensory deficitis, aggitation, resp failure, death) bacteroides fragilis (GNR, contributes to abdominal/pelvic abscesses) peptostreptococus (GPC, lives in mouth, contributes to mixed oral/lung infxns/abscess) Other bacteria chlamydia trachomatis (urethritis, cervicitis/PID) pneumoniae (fever, upper resp sx, non-productive cough) psittacosis (spread by exposure to parrots & sometmes other birds, 1-2 week incubation; fever, cough, severe HA; other organ systems as well) mycoplasma pneumoniae (common cause CAP; acute f, c, cough, upper resp sx; not usually severe) nocardia (lives in soil, causes sub-acute pneumonia, also abscess/cellulitis/lymphangitis if direct inoculation) actinomyces (oral/neck/face slow growing abscess, often w/sinus tract development, can affectother organ systems as well) Viruses rhino, adeno (common cause of upper respiratory infxn, cough, nasal congetsion, sore throat, ear pain) influenza (common cause upper and lower respiratory infection, seasonal in North America oct to april, increase risk if no vaccination; abrupt onset of myalgias, arthralgias, fever, chills) more from CDC ) rotavirus, norovirus (common cause of acute enteritis: abrupt onset n, v, d, diarrhea; rota in partic kids enteroviruses (non-specific sx of f, c, aches; meningitis) coxsackievirus (myocarditis, pericarditis, hand/foot/mouth in kids f, malaise) polio - eradicated in US w/vaccine EBV → mononucleosis (incubation 4-6w, pro-drome 1-2w of fatigue and myalgias; then f, head/neck adenopathy, pharyngitis, hepatomegaly, splenomegaly) herpes simplex (past by sexual or oral contact; genital or oral herpes, encephalitis; fever or pain prior to appears vesicles ; resolves spont; can recur, can be congenitally acquired) varicella zoster ( chicken pox , shingles → dermatomal vesicles , pneumonia in setting severe chicken pox) Hepatitis A (acute liver infection, spread fecal/oral/ingestion contaminated food, can be epidemic; incubation 2-4w, n, v, abd pain, f, jaundice , icterus ; generally self limited) B (acute liver infection, incubation 3m; spread via sexual contact, vertical, shared needles, needle sticks in health care workers, unscreened blood transfusion: acute may cause f, c, jaundice , icterus ; may be sub-acute; 95% adults resolve, 5% go on to chronic hepatitis → risk cirrhosis, HCC) C (chronic hepatitis, acute infection generally not recognized, spread via needles, unscreened blood transfusion, cocaine inhaling tools, needle sticks in health care workers, vertical, sexual - rel difficult; 10-20% resolve; long term risk cirrhosis and HCC) HPV ( genital warts , peri-anal warts , years later causes cervical cancer, head/neck scc, penile scc) RSV (winter mos, cough, fever, typically affects infants and children) para-influenza (upper resp infection/croup, tracheobronchitis) parvo (most common ages 5-19, slapped cheek rash, also rash on arms, soles, palms; acute arthralgias/arthritis that can mimic RA; can cause acute hypoprolif anemia) CMV (retinitis/colitis/disseminated dz in patients w/HIV; systemic infection in patients 1-4m s/p transplant; normal hosts get mono-like symptoms: incubation 3-8 w, then f, c, malaise hepatomegaly, splenomegaly, fatigue x 4-6w; head/neck adenopathy & pharyngitis are rare) rabies (bite from infected animal → skunk, bat, squirrel, dog; incubation can be days to mos, f, ha, myalgias, arthralgias, hydrophobia, intermitent confusion/aggitation, sensitivity to sound/light; sx onset to death avg 4d) Hanta (rodent exposure; 3-4d f, myalgias, HA, n, v, abd pain; then rapidly progressive resp sx) West Nile (incubation 2d-2w; summer/fall in North America, fever, muscle aches, confusion, ha, stiff neck, rash, confusion → meningo-encephalitis) measels (uncommon w/vaccination, winter/spring in US, cough, f, malaise, conjunctivitis, runny nose, then rash, white spots on oral mucosa; complications include encephalitis, pneumonia) mumps (uncommon w/vaccination, f, myalgia, malaise, affects B parotids and testicles) rubella (uncommon w/vaccination, rash starts on face, fever, adenopathy; can be congenitally acquired) Fungi candida (common cause of fungal skin infection: tinea cruris , tinea pedis , vaginitis; worse/recurrent if immune-compromised) Coccidioidomycosis (south west US, higher risk if immune-compromised, sub-acute pneumonia/effusions, also arthritis, skin , seeding of other sites) aspergillus (pneumonia in compromised host, tissue invasive or fungal ball, invasive sinusitis in patients w/DM or otherwise compromised, can infect any organ; recurrent wheezing in normal hosts → ABPA) histoplasmosis (can be asx/mild and resolve spont; often see x-ray evidence prior infection lung, spleen w/o known past infxn; exposure to Mississippi & Ohio river valley; cough, fever; can cause resp/systemic illness in HIV+) mucor (invasive sinusitis, pneumonia in patients w/DM or otherwise compromised; cough, fever, HA, sinus pain) pneumocystis jerovecii (pneumonia in patients w/HIV; also in those compromised by long term steroid use) Mycobacteria tuberculosis (sub-acute, cough, hemoptysis, weight loss, sweats; can also infect GI/GU tracts, bone; increased risk if immune-compromised/hiv +) more from CDC MAC (HIV + cause of diarrhea; indolent lung infection in patients with bronchiectasis) MAI (diarrhea in patients w/HIV) M Marinum ( sub-acute skin infection , after exposure via fish tanks) M Leprae (slow, anesthetic macule, area of involvement spreads, direct nerve involvement, neuropathic pain and enlargement of involved nerve, Southeast Asia) Retrovirus (HIV) HIV (hiv risk factors → men who have sex w/men, unprotected intercourse, sex w/prostitutes, sex w/somone known hiv +, ivdu, transfusion w/unscreened blood, drug/etoh abuse, hx other sti's, health care worker's w/needle stick injury; risks of unusual infection increase as CD4 declines - see organ specific sx) more from CDC Spirochetes borrelia burgdorferi → lyme (endemic area north east, upper mid west, tick contact x 24-48h; inoculation days to weeks, then-->rash, f, c, aches; then arthralgias, heart block, CNS involvement; later still arthritis) more from CDC syphillis (sexual exposure, initially painless genital ulcer → heals 4-6w; weeks later non-specific rash , w/predilection for palms , and soles , condyloma around genital areas, mucous involvement, adenopathy; late manifestations yrs later affecting CNS, large blood vessels → aortitis, aneurysm) more from CDC leptospirosis (contract via exposure to rodent/wild animal feces; inoculation period several weeks; mild dz is self limited f, c, ha, n, v, musle aches, conjunctival injection; severe dz with hepatic and renal involvement, icterus ) Rickettsiae Rock Mtn Spotted Fever (exposure to tick, incubation 2d to 2w; can occur in most states in US, f, c, ha, arthralgias, then generalized rash - though not always, can be severe/fatal) human ehrlichiosis (often co-infection w/lyme, tick born, incubation ˜1w, f, ha, n, v, myalgias; often causes BM suppression) Parasites malaria (passed via mosquitoes, live in tropical climates: Southeast Asia, Africa; susceptibility increase if don't use proph abx; incubation 1-4w; recurrent high fevers, c, HA) toxoplasmosis (protozoa, carried in cat feces, healthy hosts not affected, in HIV + causes brain infection dc4 < 200 → headache, f, delirium, szr; pregnant women can pass in utero → congenital abnl) giardia (protozoa, spread via poor hygiene, contaminated water, drinking from ponds/streams, anal intercourse; many infected are asx; incubation 1-3w; non-bloody diarrhea, gas, burping) entamoeba hystolytica → amebiasis (protozoa, acquired via unclean water/poor sanitation, also anal intercourse; only 10-20% develop sx; incubation 2-4w; abd pain, bloody diarreha; occas liver abscess) trichinosis (roundworm, rare in US; from eating infected meat; abd pain, n, v, diarrhea; after 1-2w, muscle pain when migrate to muscles, rash, ha, n, v) ascariasis (roundworm, tropics/sub-tropics/SE US, eggs swallowed if contaminated soil ingested → eggs hatch in intestines → larvae enter blood stream → migrate lungs → mature & coughed up → swallowed → mature in intestines; cough, fever, sob, n, v, abd pain, impaired growth of children, sbo) hook worm (common world-wide, enter thru feet/skin if walk barefoot in soil w/infected feces → bloodstream → lungs → swallowed → intestines → blood loss → anemia, d) enterobiasis (pin worm, fecal oral, common in kids, cause nocturnal peri-anal itching) w bancrofti (tropics/sub-tropics, spread by mosquitoes, filaria invade lymphatis, after years → lymphedema from obstruction of channels) onchocerciass (causes river blindness, Africa/central-south America; spread by black fly; conjunctivits/keratitis, skin nodules) schistomiasis (south america, middle east, caribbean, africa: flukes, invade skin of swimmers, enter blood stream → live in portal/mesenteric veins; can cause cirrhosis after years; can live in bladder → SCC after years) cysticercosis (tapeworm, ingest eggs via infected beef that's undercooked; Mexico, Africa, Southeast Asia; eggs cross intestines, migrate to host muscles and brain, can cause seizures) echinococcus (worm; from cattle and dogs; in US and many other areas; eggs ingested by humans → travel to liver, lungs, other organs → cysts form: in liver → can cause RUQ pain → compress biliary tract → if rupture can cause anaphylaxis); in lung- → can cause cough, SOB, sputum) Non-Infectious Malignancy - many cancers (e.g. renal, leukemia, lymphoma), with specific dx guided by localizing sx, careful exam and identification of risk factors Auto-immune - specific disorder based on other symptoms and findings - relatively uncommon (compared w/above) RA (sub-acute, persistent/progressive joint pain, tendency for bilateral involvement → MCPs hands , knees; warmth; redness; worse in am; women > men; fatigue) Lupus (sub-acute, female > male, black>white, sub-acute, fever and feeling poorly in general, rash on face, other system involvement → kidneys, brain) Familial Med Fevers (uncommon, associated w/cryptic abdominal pain, rash, arthritis, arthralgias, myalgias, recurrent fever) Still's disease (subacute, uncommon, rash , sore throat, arthralgias) Polymyalgia Rheumatica - PMR (sub-acute, age > 50, morning shoulder and hip aches, no findings on exam of joint inflammation) Giant Cell Arteritis (age > 50, often prior hx PMR, fatigue, headache, joint aches, visual loss) Other vasculitides Inflammatory bowel disease (sub-acute, recurrent or chronic diarrhea; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic sx; presentation can also be fulminant) Serum sickness (acute, symetric, additive/migratory, polyarthritis; myalgias, fever, rash; typically from rx to abx, or secondary to viral infxn → e.g. acute hep b; onset days to weeks after exposure) Endocrine Low testosterone (sweats but no fever, decreased libido, fatigue, errectile dysfunction) Menopause (sweats but no fever, age ˜ 50, irregular menstruation) hyperthyroidism (irritability, inability to sleep, diarrhea, palpitations, tremor, heat intolerance) adrenal insufficiency (weakness, n, v, skin darkening if central etiology) Meds: Dx based on r/o other causes and temporal link between initiation med and fever onset malignant hyperthermia → e.g. inhalational anesthetics - typically in OR or soon thereafter neuroleptic malignant syndrome → e.g. haldol, chlorpromazine (high fever, cramps, delirium, autonomic instability) many other meds - including broad range of abx Other DVT/PE (acute, cough, SOB, pleuritic, hemoptysis, unexplained unilateral leg swelling, RFs for DVT; Well's Criteria for DVT ; Well's Criteria for PE ) Vision

More Info About Eye Disorders: NIH National Eye Institute

Comprehensive eye exam

• glaucoma, macular degeneration, DM retinal disease, other
• Retinal artery occlusion (unilateral, like a "curtain dropping," other Cardio-Vascular Risk Factors)
• Retinal vein occlusion (unilateral, other C/V RFs)
• Retinal detachment (unilateral, floaters, flashes)
• Vitreous hemorrhage (unilateral, diabetes, trauma)
• Stroke (acute, loss of specific visual field, other C/V RFs)
• Acute angle glaucoma (unilateral, red)
• Infection - any eye/peri-orbital structure aside from conjunctiva (unilateral, discharge, red, trauma, foreign body)
• optic neuritis (acute, sometimes painful, known MS, waxing and waning symptoms of sensory or motor loss, non-specific dizziness)
• Macular degeneration (initially vague, ultimately central field loss, uni or bilateral)
• Refractive errors: near or far sighted (bilateral)
• Cataract (uni or bilateral)
• Glaucoma (uni or bilateral)
• Retinal disease (history poorly controlled diabetes, htn)
• Stroke (acute, other neuro Sx, C/V RFs)
• Tumor (known central nervous system tumor affecting cranial nerves, loss of other discrete neuro fxns)
• myasthenia gravis (slowly progressive, generalized muscle weakness, worse w/use, improves w/rest)
• nerve entrapment → e.g. following trauma, orbital fracture
• Monocular - present with even one eye closed → refractive error or other localeye problem
• Conjunctivitis (conunctival redness, itching, painless, no visual change, uni- or bilateral)
• other infectious, allergic
• Viral → (redness of conjunctiva, URI sx, watery discharge, no visual change, uni- or bilateral, gritty sensation)
• Bacterial → (redness of conjunctiva, pus, no visual change, uni- or bilateral)
• Allergic (itchy, watery d/c, chronic, no visual change)
• Blepharitis (redness along eye-lid margins, itchy, no visual loss)
• Episcleritis (redness of superficial layer of sclera, uni- or bilateral, assoc w/auto-immune d/o, often remits spontaneously)
• sub-conjunctival hemorrhage (no d/c, no pain, no visual sx, unilateral)
• Ectropion → (inside of lower lid chronically exposed, chronic conjunctival redness, dryness, no pain or visual loss)
• Dacrocystitis (acute pain and redness over medial lower lid where tears drain, acute, no visual loss, unilateral)
• Dry eyes (chronic, mild redness, bilateral, itchy)
• Bacterial (some hyperacute bacterial infections are painful and cause visual los- e.g. gc)
• Herpes- conjunctivitis, keratitits, scleritis (pain prior to erruption, vessicles, visual loss, unilateral)
• Scleritis → (redness of deeper layer of sclera, darker discoloration compared w/episcleritis, assoc w/auto-immune d/o, no visual loss)
• Keratitis → (acute, painful, visual loss, inflammation in cornea, unilateral)
• Corneal abrasion (acute, painful, related to local trauma or foreign body, visual loss, unilateral)
• Acute angle closure glaucoma (unilateral, visual loss, acute, globe feels hard)
• Other infection/inflammation: iritis, anterior chamber infection
• hyperbilirubinemia from liver dz
• Chalazion/hordeolum (acute/sub-acute, discomfort, red bump, preserved vision, focal redness)
• skin around eye: pre-septal cellulitis (acute, red, painful, preserved vision)
• orbital cellulitis (acute, decreased vision, pain w/eye movement, head ache, peri-orbital redness)
• fleshy growth on sclera: pterygium

Head and Neck (H&N)

More Info About Head and Neck Disorders: National Library of Medicine/Medline Plus

Comprehensive head and neck exam

• infection , inflammation, trauma, other
• Squamous cell CA (RFs for CA: smoking, drinking, chewing tobacco)
• Herpes Simplex Virus
• Fungal (white discharge, bleeds, immune-suppressed)
• HIV related
• Inflammatory/autoimmune
• apthous ulcer
• IBD related
• Bechets Dz (eye & genital lesions)
• Medication related
• Lymph nodes
• Lymphoma (diffuse LN enlargement, sweats, fever, wt loss)
• Infection (w/in lymph nodes themselves or assoc w/infection in/around mouth)
• Thyroid (near mid-line anterior)
• Parotid (either side of face in cheek area; inflammatory → acute, painful; non-inflammatory/malignant →slowly progressive, painless)
• wax (slow, uni- or bilateral, painless)
• bony growth (slow, uni- or bilateral, painless, hx extensive swimming)
• Otitis externa (cute, painful, discharge)
• tympanic membrane perforation (acute, trauma, discharge, pain)
• effusion → following Sx otitis media (ear pain, acute, cough, nasal congestion)
• age and noise related (slow, bilateral, older)
• acoustic neuritis (abrupt, unilateral)
• ototoxic meds → aminoglycosides, cisplatin
• Menierres (hearing loss accompanied by dizziness, tinnitus)
• Mixed sensori-neural and conductive
• middle ear infection → otitis media (acute, cough, nasal congestion)
• outer ear → otitis externa
• Viral (acute, cough, colored D/C, self limited)
• Bacterial (acute, cough, persistent, colored D/C, fever, tooth or facial pain)
• Allergic rhinitis (chronic, cough, clear D/C)
• Cancer (red flags: progressive, cough, hemoptysis, smoking, SOB)
• Nodules/polyps (slow, worse w/talking, improves w/rest)
• Infection (acute, pain w/talking, cough)
• GERD (epigastric discomfort, radiates upward under sternum, worse lying down, bad taste in mouth, chronic/recurrent)
• Parkinson's disease (age > 50, bradykinesia, tremor)
• Cancer of: thyroid, larynx, mediastinum, other head/neck
• Other cause of cord paralysis
• Overuse - hx persistent speaking, loud voice (work related shouting, singing, no red flags)
• Dental infection , poor chronic care, lack of access to dentists
• GERD (heartburn, bad taste in mouth when lie down)
• Cancer (hx smoking, etoh, slowly progressive sx)
• Psychogenic

More Info About Pulmonary Disorders: National Heart, Lung and Blood Institute

Comprehensive pulmonary exam

• COPD, asthma, other
• health care associated: hospitalized x2d within last 3m; also consider patients on HD, in NH, on recent IV abx; many of these patients w/sig underlying medical conditions; flora changes to gnr's, mrsa, other resistant organsisms - though could still be CAP organisms
• viral (influenza: acute, Sept → March, fever, chills, muscles aches, no hx vaccine)
• cocci (acute or sub-acute, live in southwest)
• histoplasmosis
• TB can occur at any CD4, if > 350, similar sx to non-hiv + → cough, fever, sweats, sob, hemoptysis; CD4 < 350, extra-pulmonary TB increases)
• MAC (subacute, hx bronchietasis → copd, prior lung infections w/parenchymal destruction)
• Chemotherapy w/neurtopenia (increased risk pseudomonas, TB, fungal - though also can be typical bacterial pathogens)
• HIV - see below
• Cancer (sub-acute, cough, wt loss, hemoptysis, smoking and/or asbestos exposure, chest pain)
• COPD (sputum, acute or chronic, cough, smoking, wheezing or other exam findings )
• Asthma (acute or chronic, cough, wheezing, or other exam findings )
• Pneumothorax (acute, SOB, pleuritic, trauma, smoker, absent breath sounds )
• other inflammatory/infiltrative processes
• Pulmonary emboli (acute, cough, SOB, pleuritic, hemoptysis, RFs for DVT ; Well's Criteria for DVT ; Well's Criteria for PE )
• Primary: (women > men, vague chest pain, subacute sob worse w/activity, dizziness with activity; elevated jvp, edema, right ventricular heave, loud p2, rapid heart rate )
• Secondary from: sleep apnea, chf, chronic pulmonary emboli, HIV, connective tissue d/o if hx scleroderma or rheum arthritis; congenital heart disease
• cancer (SOB, sub-acute, cough, wt loss)
• para-pneumonic (secondary to adjacent infection, but fluid not infected - aspiration to dx)
• empyema (fluid infected - complication of pneumonia, lung surgery, trauma - persistent f, c, sob - aspiration to dx)
• cirrhosis associated (portal hypertension, ascites )
• Rheumatoid arthritis
• Surgery - with manipulation in are near apex of lung
• Cancer - occluding lymphatics
• Primary (tall thin male, smoker)
• Secondary (trauma, chronic infection-->hiv, severe copd)
• Neuromuscular disease (generalized weakness, other neuro Sx)
• phrenic nerve injury (post thoracic surgery, absence of diaphragmatic excursion on percussion )
• Systolic heart failure (Known CAD/MI, HTN, hx cardiomyopathy, chronic SVT)
• Diastolic heart failure (chronic poorly controlled htn; age > 50; infiltrative processes that decrease compliance → amyloid, etc)
• Pericardial disease (hx open heart surgery, hx pericardial inflammatory process)
• A-V fistula (trauma, inflamation or surgery induced)
• hyperthyroidism (weight loss, tachycardia, diarrhea, tremor)
• thiamine deficiency (ETOH abuse, confusion, extremity numbness/difficulty walking)
• Paget's disease (> 50, slowly progressive multi-site bone pain, leg bowing)
• CAD (other C/V RFs, pressure w/walking, radiation to L arm/neck/back, sweating, N)
• Valvular heart disease - in particular: aortic, mitral with characteristic murmurs , often associated with Sx of CHF
• SVT (rapid heart rate, palpatations)
• bradycardia (fatigue, decreased exercise tolerance, CHF symptoms)
• anemia (see under fatigue , known blood loss, known problem with blood production, hemolysis)
• deconditioning (inactivity) , etc
• renal failure
• volume overload for any reason
• panic attacks/anxiety disorder
• Pneumonia (acute, cough, SOB, sputum production, fever)
• Cancer (sub-acute, SOB, cough, wt loss, hemoptysis, smoking and/or asbestos exposure)
• Pneumothorax (acute, SOB, pleuritic, trauma, smoker)
• Stable angina (known cad, sx occur after a predictable amount of work, never at rest, not progressive, resolve when stops activity)
• Unstable angina (known cad, sx at rest, progression of symptoms such that occurring with less and less activity)
• Myocardial infarction (chest pressure from acute ischemia, n, v, sob, diaphoresis, hx known cad or vascular disease elsewhere)
• Aortic dissection (C/V RFs, tearing type CP, radiation to back)
• Viral (antecedent respiratory viral sx → fever, cough, sweats)
• Post MI (known recent heart attack)
• Post cardiac surgery
• Advanced kidney disease
• Hypothyroidism
• Lupus (arthralgias/arthritis, fever, fatigue, facial rash, female>male, black/asian/hispanic>white, age 15-30s)
• Scleroderma (GERD, raynauds → fingers blanch/hurt when exposed to cold temp , skin thickening/tightness )
• Mixed connective tissue d/o (fatigue, muscle and joint aches, raynauds → fingers blanch/hurt when exposed to cold temp , finger swelling)
• GERD (sub-sternal pain radiating upwards, bad taste in mouth, worse lying down)
• Esophageal spasm
• Esophagitis
• Infection (viral, fungal → acute, immuncompromised)
• Pill induced (pain after ingesting pill→ not fully swallowed)
• Musculoskeletal (worse w/movement, Hx overuse/injury)
• Neuropathic pain from Zoster (burning, localized to dermatome, vesicular rash several days after pain onset)
• Pneumonia (fever, colored sputum, SOB, acute, systemic Sx)
• Sinusitis (acute sense of sinus/facial fullness, anterior nasal discharge, post nasal drip, sore throat)
• Bronchitis (acute, sputum production, symptoms of infection in any contiguous space in the upper respiratory tract, not seriously ill)
• Pertussis (persistent cough x weeks, coughing so hard that vomit, not seriously ill otherwise)
• Acute Exacerbation Chronic bronchitis - AECB (Hx COPD, Sob, colored sputum, wheezing, acute)
• Asthma (acute or chronic, wheezing, SOB)
• COPD (acute or chronic, sputum, wheezing, SOB, smoking)
• Cancer (SOB, known cancer, wt loss, smoking, asbestos, chest pain, hemoptysis, sputum)
• Other parenchymal process
• Pulmonary emboli (acute, cough, chest pain w/breathing, hemoptysis, RFs for Deep Vein Thrombosis ( DVT ))
• GERD (heartburn, chronic)
• Rhinitis (post nasal drip, chronic or acute)
• Meds - ace-inhibitors (ACE-I) , angiotensin receptor blockers (ARBs)
• Tumor (hx smoking, age > 50, progressive sx)
• Infection (acute, purulent sputum, fever)
• Cancer (persistent, smoking and/or asbestos exposure, SOB, cough)
• Bronchitis or pneumonia (acute, sputum, fever, SOB)
• Tuberculosis (sub-acute, fever, sweats, SOB, weight loss, HIV/otherwise immune-compromised)
• Bronchiectasis (fever, cough, sputum, SOB, Hx COPD)
• Pulmonary embolism (acute, cough, SOB, pleuritic, hemoptysis, RFs for DVT )
• Other parenchymal or vascular inflammatory process
• Contribution from primary bleeding disorder &rarr see under Hematology/Oncology - Abnormal bleeding/bruising
• Bleeding from GI source →esophagus, stomach w/aspirated blood coughed up and/or vomiting mistaken as hemoptysis
• Asthma (intermitent, known Hx, response to precipitant)
• COPD (SOB, DOE, sputum, intermitent or constant, smoking Hx)
• pulmonary edema aka - "cardiac asthma" - Sx CHF (C/V RFs, orthopnea, PND, exam findings: lower extremity edema , + S3 , elevated jvp , displaced pmi , rales on lung exam )
• stridor → upper airway obstruction
• lower airway obstruction from foriegn body (young child, Hx aspiration, altered mental status)
• other pulmonary parenchymal inflammatory process
• Cancer w/airway obstruction (smoking, asbestos, cough, hemoptysis, weight loss, SOB)
• Allergic reaction (acute, temporally related to med, hx med reaction, hives)
• obstructive sleep apnea (obesity, snoring, witnessed apnea, not rested when awaken, day time fatigue)

Cardiovascular (C/V)

More Info About Cardiovascular Disorders: National Heart, Lung and Blood Institute

Comprehensive cardiovascular exam

• Hypertenion, hyperlipidemia, congestive heart failure, valvular heart disease, coronary artery disease, peripheral vascular disease, stroke, etc
• Esophageal spasm (acute, intermittent, swallowing problems)
• Anxiety/panic disorder
• Neuropathic → Zoster (burning, localized to dermatome, vesicular rash)
• Valvular heart disease - in particular: aortic, mitral - often w/Sx CHF
• Pneumonia (acute, cough, sputum production, fever, chest pain)
• COPD (acute or chronic, cough, smoking, wheezing)
• Asthma (acute or chronic, wheezing, cough)
• Pulmonary HTN (slowly progressive, Hx HIV, Hx IVDU)
• infection (acute, F, cough, sputum, SOB)
• phrenic nerve injury (post thoracic surgery)
• anemia ( fatigue , known blood loss, known problem with blood production, hemolysis)
• L sided CHF → systolic and diastolic dysfxn CHF (C/V RFs, orthopnea, PND, exam findings: lower extremity edema , + S3 , elevated jvp , displaced pmi , rales on lung exam )
• R sided CHF → pulmonary htn, L sided CHF
• Portal htn → cirrhosis (known liver disease from viral/etoh/other chronic hepatitis, ascites , jaundice , icterus )
• Venous insufficiency (chronic, worse after standing, dark skin discoloration)
• Advanced liver disease (known liver disease from viral/etoh/other chronic hepatitis, ascites , jaundice , icterus )
• Malnutrition (lack of access to calories, disadvantaged Socio-economic status, temporal wasting )
• Loss of protein in urine → nephrotic syndrome
• cirrhosis (chronic liver dz → hep C, ETOH)
• Infection (redness, pain, fever)
• DVT (acute, localized discomfort, RFs: hypercoaguable state, immobility, trauma; Well's Criteria )
• lymphatic injury (lymph node dissection, trauma)
• obstructing cancer
• Venous insufficiency (chronic, Hx saphenous vein harvest w/CABG, worse after standing, dark skin discoloration)
• Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF )
• Bradycardia ( fatigue , decrease exercise tolerance, CHF Sx)
• SVT (rapid/irreg heart beat, palpatations)
• Aortic stenosis → characteristic murmur
• hypovolemia (bleeding, diarrhea , Sx provoked by standing, +orthostatic vital sign changes )
• orthostatic blood pressure changes
• from autonomic dysfunction (Hx diabetes, other neuropathy)
• cerebral vascular disease affecting vertebral-basilar system (vascular risk factors; symptoms/findings in territory supplied by v-b system: sudden dizziness, double vision, swallowing/speech problems, nausea, vomiting)
• Seizure d/o
• intracranial process → blood, tumor, trauma
• hypoglycemia (known DM & Rx w/meds)
• drug overdose, e.g. heroin
• Supraventricular tachycardia (SVT): atrial fibrillation, atrial flutter, a-v nodal re-entrant tachycardia
• Ventric tachycardia (red flags: syncope/presyncope , abrupt, resultant fall w/injury, Hx CAD, Hx CHF )
• Premature ventricular contraction, atrial premature contraction (awareness of extra beat, early beat, strong beat; No SOB, CP, CHF Sx, presyncope/syncope)
• Acute physiologic response (fever, pain, hypovolemia, stress)
• Panic/anxiety d/o (anxiety, panic, depression, terror, multi-system concerns w/o organic disease)
• Meds/toxins (cocaine, caffeine) cigarettes, sympathomimetics)
• subacute/chronic (from progressive athero, calf cramps/pain, worse w/activity, better w/rest, feet progressively cool, hairless, diminished cap refill, ulcers )
• acute (sudden pain from abrupt artherial occulsion; embolit from a fib w/o coumadin, or ventricular thrombus if severe lv dysfxn; recent catheterization where plaque disrupted from aorta; blue/hypoperfused toes )
• Spinal stenosis (radiates down back both legs, worse w/walking, better leaning forward)
• electrolyte abnormalities, other
• Cramps - often non-specific (hypokalemia, dehydration, hypocalcemia, idiopathic)
• Peripheral Arterial Disease - PAD (progressive, C/V RFs, better w/rest, better w/dangling legs, worse w/leg elevation; exam findings: lost of pulses, decreased cap refill )
• diabetes (PAD, neuropathy)
• venous insufficiency (chronic swelling, worse at end of day)
• peripheral neuropathy
• skin cancer

Gastrointestinal

More Info About Gastrointestinal Disorders: National Digestive Diseases Clearinghouse

Comprehensive GI exam

• ulcers, hepatitis, inflammatory bowel disease, cancer, irritable bowel syndrome, etc
• Gastroesophageal Reflux Disease (worse after meals, worse if lie down after eating, bad taste in mouth, obesity, ETOH, smoking, caffine, chocolate)
• Pill induced (pain after ingesting pill → not fully swallowed)
• C/V disorders
• Primary pulmonary disorders
• Gastroenteritis (self limited, N, V, D, others similarly ill)
• Peptic ulcer Dz (epigastric, better or worse w/food, nsaid use, black stools, hematemesis)
• Pancreatitis (epigastric, constant, radiates to back, N, V, ETOH abuse)
• Cholecystits (constant, right/upper abd, fever, nausea)
• Biliary colic (episodic, after meals, right upper quadrant)
• MI (acute, N, V, SOB, CP, C/V RFs)
• Pneumonia (acute, sob, cough, sputum, fever, CP)
• GERD (epigastric, radiates upward under sternum, worse lying down, bad taste in mouth)
• Non-ulcer dyspepsia (epigastric, better or worse w/food; no red flags)
• Mesenteric/small bowel ischemia (generalized abd pian, known atherosclerosis or RFs, pain after meals →angina of the gut, weight loss, food avoidance)
• Functional constipation (no red flags)
• Inflammatory Bowel Disease - upper or lower abd (sub-acute, recurrent or chronic; wt loss, diarrhea, bloody stools, cramps, constipation; presentation can also be fulminant)
• Gastric (red flag Sx: anorexia, weight loss, epigastric, persistent/progressive, N, V, early satiety)
• Pancreatic (red flag Sx: anorexia, weight loss, epigastric pain radiating to back, persistent/progressive)
• Liver (red flag Sx: anorexia, weight loss, right upper quadrant, persistent/progressive, Hx chronic Hepatitis)
• Biliary (red flag Sx: anorexia, weight loss, epigastric/right upper quadrant, persistent/progressive, jaundice, ictreus, white stools)
• Colon (red flag Sx: anorexia, weight loss, vague pain, persistent/progressive, bloody stools, change in bowel habits, pain w/defecation)
• Lymphoma (red flags: wt loss, sweats, adenopathy elsewhere)
• Metastatic disease to abdomen e.g. &rarr Lung
• Bowel obstruction (comes in waves, generalized, N, V, decreased flatus, abd distention)
• Diverticulitis (left/lower abdomen, fever, nausea)
• Appendicits (starts umbilicus → R lower queadrant, fever, nausea, anorexia)
• Abdominal aortic aneurysm (vague umbilical Sx, radiating to back, C/V RFs)
• Hernia - incarcerated or strangulated (inguinal area, severe)
• Mesenteric/small bowel ischemia (known atherosclerosis or risk factors, known risk factors for embolic disease →a fib, ventricular thrombus, acute low BP superimposed on atherosclerosis, persistent/progressive generalized pain w/few exam findings)
• Colonic Ischemia (mild generalized abdominal pain, known atherosclerosis or RFs, small amounts of bright red blood w/stool, diarrhea, hypotension from other process superimposed on atherosclerosis, RFs for embolic events → a fib, ventricular thrombus)
• Renal stones (colicky, radiates from flank towards pelvis, N, V, hematuria)
• simple UTI (acute, frequency, urgency, no vaginal d/c if female, no other Sx)
• complex infection/pyelonephritis (fever, chills, lower abd/low back pain)
• Testicular torsion (acute, unilateral, n, v)
• Testicular/epididymal infection (acute, unilateral, dysuria, frequency, fever, sexual activity)
• Ectopic pregnancy (sharp, vaginal bleeding, sexually active)
• Pelvic inflammatory disease (vaginal D/C, fever, sexually active)
• cyst rupture (mid-menstrual cycle, gradual onset)
• torsion (severe, N, V)
• malignant stricture (red flags: progressively worse w/time, food "sticks" in same place, wt loss, RFs: smoking, ETOH abuse, long standing reflux)
• web or ring
• GERD related stricture (long Hx GERD)
• stroke (acute, other vascular risk factors, problems w/initiating, other focal findings)
• Neuro-muscular (botulism, guillain barre, myasthenia → acute, progressive, other neuro findings)
• dental problems (prevent chewing and/or cause pain)
• esophageal (Progressive swallowing problems→ food gets stuck, worse w/solids then liquids, pain, >50, chronic GERD, smoking, ETOH abuse)
• gastric (feel full when eating ever small quantities of food., pain, >50, smoking, ETOH abuse)
• esophageal dysmotility
• esophageal spasm (acute, intermittent)
• Scleroderma (skin tightening→ https://medpics.ucsd.edu/index.cfm?page=skin_sclerodactyly.htm, women > men,
• gastric stricture (history ulcer disease, surgery)
• esophageal web or ring
• esophageal stricture (long hx gerd)
• Zenker's diverticulum (chronic symptoms, bad breath, sensation food stuck in throat, regurgitation undigested food)
• achalasia (progressive dysphagia, solids and liquids, regurgitation, lower area esophagus)
• esophageal spasm
• viral/fungal infection (acute, often immune compromised)
• pills (acute, occurs after a pill stuck)
• esophageal cancer (hx GERD, progressive symptoms, dysphagia)
• malignancy (red flags: age > 50, wt loss, smoking, after each meal, progressive)
• autonomic nerve dysfunction - e.g. w/DM (neuropathic Sx elsewhere)
• benign stricture (Hx ulcers, chronic GERD )
• gastroenteritis (acute, w/diarrhea)
• small or large bowel obstruction (abd pain, distention, Hx surgery → adhesions, decreased flatus, decreased bowel movements)
• increased intracranial pressure (HA, trauma, cancer)
• toxins, etc
• generalized systemic infections
• myocardial ischemia
• increased vagal tone
• liver failure
• Fluid within peritoneum → ascites (known cancer, advanced liver disease, TB/chornic infxn)
• Gas → bowel distention or obstruction
• Organomegaly → liver, spleen, kidney, uterus (pregnant v other) , bladder
• ventral hernia (past surgery, bulge thru scar line, increases w/straining)
• Stone in common bile duct (acute, if also infxn: RUQ pain, F, N, systemic illness)
• Common duct or pancreatic cancer (sub-acute, painless, age > 50, wt loss)
• Chronic liver dz - Hep C, Etoh, Hep B (long duration illness)
• beta carotene overdose
• Ulcer (epigastric, better or worse w/food, nsaid use, black stools, ETOH)
• varices (chronic liver disease → portal hypertension)
• gastritis (stress, ETOH)
• esophagitis (GERD Sx)
• Swallowed blood from upper respiratory source → nose bleed
• Swallowed blood from mouth source
• Contribution from primary bleeding disorder → see under Hematology/Oncology - Abnormal bleeding/bruising
• Iron supplementation
• Pepto Bismol
• diverticulum (acute, bright red blood)
• hemorrhoid (painless if internal ; painful if external and thrombosed )
• Fissue (acute, painful)
• Inflammatory
• inflamatory bowel disease (sub-acute, recurrent or chronic diarrhea; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic Sx)
• bacterial (acute, F, bloody stool, abd pain; prior abx use &rarr c dif)
• parasites →Ameobiasis (camping/drinking unfiltered water)
• HIV (chronic, atypical infxns → parasite, fungal)
• Colonic ischemia (acute, pain, hx vascular disease and RFs, hx hypoperfusion → hypotension for any reason)
• low fiber diet
• Irritable Bowel Syndrome (chronic, crampy pain, no wt loss, no blood in stool; no systemic Sx; occasional diarrhea)
• Obstruction
• distal cancer (red flags: sig pain, blood, wt loss, progressive)
• stricture (prior surgery, IBD or other inflammatory process)
• Fecal impaction (low liquid intake, impaired awareness/cognition, chronic Low motility)
• Metabolic/Endocrine
• Hypo-thyroid (wt gain, edema, dry skin, constipation, cold intolerance, depression, hair loss)
• Hypcercalcemia (polyuria, constipation, confusion, Bone pain, known/suspected squamous cell ca)
• Hypo/hyperkalemia (older, diuretic use, risk for low or high k)
• Diabetes (known dz, poor control→polyuria, polydypsia, neuopathy)
• Spinal cord problems (trauma, urinary incontinence, lower extremity weakness, numbness, other RFs for cord problems→cancer, infection)
• Peripheral neuropathy
• Poorly controlled dm
• Meds →narcotics, anti-cholinergics
• distal colon malignancy (red flags: progressive, wt loss, pain, blood in stool, nocturnal diarrhea)
• benign stricture (prior surgery, IBD or other inflammatory process)
• Inflammatory Bowel Disease (sub-acute, recurrent or chronic; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic Sx; presentation can also be fulminant)
• bacterial (acute, F, bloody stool, abd pain, prior abx use → c dif)
• viral (acute, fever, abd pain)
• Isosporiasis (associated with drinking untreated water, CD4
• Cryptosporidium (acute or subacute profound diarrhea, abdominal cramps, fever, n, v, CD4
• Microsporidiosis (associated with drinking untreated water, CD4 keratitis, encephalitis, other)
• Histoplasmosis (CD4
• MAI (CD4 causing adenopathy or organomegaly, anemia)
• CMV (CD 4 retinitis)
• Kaposis (CD4
• Lymphoma (sub-actue, f, sweats, wt loss, adenopathy elsewhere, unexplained organogmegaly)
• Staph toxin assoc diarrhea (sx of abrupt onset n, v, cramps, d; secondary to eating contaminated food, occurs hours after consumption, other affected who ate similar, self limited)
• Traveler's diarrhea (n, v, cramps, diarrhea after travel to another country - central/south America, asia, africa; secondary to variety of enteric pathogens, from consuming undercooked food/poor hygiene in restaurants/untreated water)
• chronic pancreatitis (multiple past episodes pancreatitis, ETOH abuse or other chronic exposure to pancreatitis inducing toxins/process, chronic upper abdominal pain, back pain, nausea, vomiting)
• lactose intolerance (n, bloating, gas, abd discomfort → within 2 hours eating milk/milk products)
• Irritable Bowel Syndrome/Functional (chronic, no wt loss, crampy pain, no systemic Sx, no blood, sometimes constipation)
• hyperthyroidism (irritability, inability to sleep, weight loss, palpitations, tremor, heat intolerance)
• laxative, sorbitol, other meds abuse
• excessive caffeine intake, etc.

Genito-Urinary

More Info About GU and Renal Disorders: National Kidney and Urologic Diseases Clearinghouse

Comprehensive male genital/rectal exam

• BPH, cancer, stones, intrinsic renal disease, etc
• Malignancy of GU tract (red flags: persistent gross blood, age > 50, male, hx smoking)
• Stones (pain, frequency, urgency, nausea, vomiting)
• Infection (acute, pain, frequency, urgency, fever)
• muscle breakdown → extreme muscle activity
• meds → statins
• bilirubin (jaundice, chronic liver disease )
• dehydration → concentrated urine
• Beet ingestion
• meds → e.g. rifampin, pyridium
• Contribution from primary bleeding d/o → see under Hematology/Oncology - Abnormal bleeding/bruising
• Beeturia -urine colored red from eating beets
• other e.g. stones, malignancy
• Sexually Transmitted infxn (+ sexual active, urethral d/c, hx past STI)
• Benign Prostatic Hypertophy - BPH (chronic, progressive, urgency, frequency, hesitancy, difficulty starting/stopping stream, incomplete emptying, decrease force, voiding again soon after urinate) AUA BPH Symptom Index - AUASS/IPSS - page 277
• Over production of urine e.g. diabetes
• Meds/drugs: diuretics, ETOH
• CHF → redistribution of volume w/lying down
• Detrussor over activity (sudden urgency)
• Detrussor under activity → overflow
• BPH (see above - urination @ night)
• urethral stricture (hx STI, trauma)
• stress incontinence (women > 50, childbirth, worse w/cough/sneeze/sudden movement)
• complication of prostatectomy
• excess urine production → poorly controlled DM, diuretic use
• infection, delirium, immobility, etc
• BPH (chronic, progressive, urgency, frequency, hesitancy, difficulty starting/stopping stream, incomplete emptying, decrease force, voiding again soon after urinate)
• infection (acute, pain, frequency, urgency, fever)
• cancer (red flags: persistent gross blood, age > 50, male, hx smoking)
• stone (pain, frequency, urgency, nausea, vomiting)
• strong and sudden → detrussor over activity
• diuretic use
• excessive ETOH and/or PM oral liquid intake
• BPH AUA BPH Symptom Index (ACP)
• decreased bladder contraction (peripheral neuropathy - sensory or motor)
• urethral stricture (men: Hx urethral trauma, Hx gonorrhea, Hx pelvic xrt, Hx prostate surgery)
• spinal cord problem (injury, infection, tumor, other → multiple sclerosis, etc)
• problem with libido/lack of interest (+ morning erections, + erections w/some partners)
• decreased testosterone (fatigue, weakness)
• meds (many - in particular anti-depressants)
• chronic medical conditions
• renal & liver disease, anemia
• problem getting &/ or maintaining erection (no AM erections, occurs w/all partners, + libido)
• In-flow probs → Arterial disease (C/V RFs, known vasc dz)
• Nerve dsyfxn (hx CNS or PNS d/o, dm)
• Outflow problems → inapprop drainage (idiopathic)
• Structural probs w/cavernosa
• Past trauma
• Inappropriate curvature from fibrosis (Peironies)
• Sexually Transmitted Infection (STI) - Gonorrhea or Chlamydia
• Infection (pain w/urination, penile D/C)
• torsion (acute, unilateral, severe)
• Cancer (progressive, painless)
• hydrocele (painless)
• Syphiliis (hx STIs, acute ulcer, painless, resolves spontaneously)
• Herpes Simplex Virus (hx STIs, acute, painful, vesicles, recurrent, resolve spontaneously)
• Human Papillomavirus (hx STIs, persistent, painless)
• Donavanosis → granualoma inguinale (tropics & not in US unless travel, spread by direct sexual contact, incubation 1-3m, papule to painless ulcer in genital area, beefy red/bleeds, develops over weeks, can be hard to distinguish from chancroid, RF for HIV)
• lymphogranula venereum (caused by chlamydia trachomastis, spread by sexual contact, rare in US, incubation 1-3 weeks, painless papule or ulcer on penis/vagina/rectal area, then painful adenopathy, RF for HIV)
• SCC (non-healing progressive, ulcer ;hx HPV)
• BCC, melanoma
• Increased risk for: HPV, HIV, Hepatitis B, Syphilis, other
• Risks as per STIs

Hematology/Oncology

More Info About Oncology and Hematology Related Disorders: National Hematologic Diseases and National Cancer Institute/

• employ multi-system ROS to define
• Acute - bacterial
• Localize site by Sx - e.g.:
• UTI (urinary frequency, urgency, burning, lower abd pain)
• Pneuomnia (cough, colored sputum, SOB)
• Acute-Viral
• Influenza (cough, muscle aches, fatigue)
• Other viral →Localize site by sx
• Acute retroviral
• HIV (Sore throat, adenopathy, rash, fatigue, HIV RFs: men having sex w/men, sex w/prostitutes, IVDU, transfusion w/o screening, sexually active, past STI)
• Sub-acute or Chronic
• HIV (generalized sx→wt loss, fatigue; HIV RFs: men having sex w/men, sex w/prostitutes, IVDU, transfusion w/o screening, sexually active, past STI, TB, sex w/anyone w/HIV RFs, sex for money)
• TB (cough x weeks, hemoptysis, wt loss; immunocompromised→malnourished, chronic steroids, known HIV or HIV RFs, malnutrition; endemic area)
• Sub-acute bacterial endocarditis (known valvular heart dz, recent bacteremia→de novo infection or procedure induced)
• Non-Infectious
• Malignancy - localize by symptoms
• Solid tumor
• Lung (sob, smoker, cough)
• Colon (BRBPR, change in bowel habits)
• Pancreas (upper abd pain, wt loss, jaundice)
• Liver (upper abd pain, jaudice, chronic hepatitis)
• Lymphoma (adenopathy)
• Auto-immune/Rheumatologic - localize by sx
• Lupus (facial rash, joint pain, joint swelling, fatigue)
• PMR (age > 50, fatigue, hip and shoulder pain, worse in am)
• Giant Cell Arteritis (age > 50, hip/shoulder pain, worse in am, fatigue, headaches, scalp tenderness, visual loss)
• RA (persistent/progressive; bilateral: MCPs hands, knees; warmth; redness; worse in am; women > men; fatigue)
• low quantity
• impaired function from: aspirin, clopidogrel, renal failure, von Willebrand's disease, other
• e.g. coumadin use, heparin
• Hereditary - bleeding problems noted from birth or early life (e.g. hemophilia)
• lymphoma, metastatic disease
• bacterial or viral
• primary CA in an organ v metastatic disease v other
• benign → lipoma, cyst, etc
• Malignancy, immoblility, trauma, smoking, Meds
• Protein s, protein c, AT3 deficiency, factor 5 leiden abnormality
• anti-phospholipid anti-body syndrome

Ob/Gyn/Breast

More Info About Ob/Gyn/Breast Disorders: National Library of Medicine/Medline Plus

Comprehensive breast exam

• Infertility, endometriosis, infection, cancer, etc
• Pregnancy (sexually active, morning sickness, abdominal swelling, planned pregnancy)
• Cancer - uterine or cervical - (hx uterine or cervical ca, age > 50, bleeding after menopause)
• Fibroids (known fibroids, abdominal pain or pressure)
• Menopause (age > 40, sweats, hot flushes, vaginal dryness)
• Dysfunctional Uterine Bleeding (excessive bleeding, bleeding between periods, no exam/lab/hx to suggest other)
• Ectopic pregnancy (known pregnancy, past STI, lower abdominal pain)
• Cervicitis → gc or chlamydia (sexually active, vaginal d/c)
• Primary bleeding d/o ( hematology )
• peri-menopause (hot flashes, vaginal dryness, age near ~50)
• auto-immune/inflammatory
• # went to term? complications? infertility?
• Vagniniitis: fungal, bacterial (acute, odor, itch, irritation)
• Cervicitis: STI (discharge, lower abd/pv pain, sexually active)
• tubo-ovarian abcess (pain, fever, acute, discharge)
• malignancy (increase w/time, firm)
• benign → cysts, fibrous tissues (size varies w/menstrual cycle)
• nipple inversion → https://medpics.ucsd.edu/index.cfm?page=thorax_retracted_nipple.htm (malignancy)
• skin puckering/retraction/chronic inflammatory (malignancy)
• milk, cyst fluid
• malignancy (bloody)
• milk when not post partum or male → increased prolactin (HA, visual Sx, infertility)
• mastitis (post partum)
• cyclic (partic time of menstrual cycle)
• cervicitis (discharge, lower abd/pv pain, sexually active)
• infertility → tubal scarring via PID
• cervical CA via HPV
• HIV, Hepatitis B, syphilis, other

Neurological

More Info About Neurologic Disorders: National Institute of Neurological Disorders and Stroke

Comprehensive neuro exam

• Stroke, seizure, neurodegenerative - Multiple sclerosis, ALS, etc
• stroke if loss is persistent; TIA if transient (known cardiovascular disease; C/V RFs: Smoking, diabetes, early family history, male, age > ˜ 50, HTN, Hyperlipidemia, Hx atrial fibrillation)
• CNS or PNS trauma
• Intoxication/drug overdose
• hypoglycemia (known DM & Rx w/meds)
• Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
• Bradycardia (fatigue, decrease exercise tolerance, CHF Sx) , SVT (rapid/irreg heart beat, palpatations)
• hypovolemia (bleeding, diarrhea, Sx provoked by standing)
• Aortic stenosis (progressive, known valvular heart disase, SOB/DOE)
• Orthostatic blood pressure change from autonomic dysfunction (Hx diabetes, other neuropathy)
• Cerebral vascular disease affecting vertebral�basilar system ((vascular risk factors; symptoms/findings in territory supplied by v-b system: sudden dizziness, double vision, swallowing/speech problems, nausea, vomiting)
• drug use/overdose/toxin
• hypoglycemia
• delirium, etc
• Primary Seizure d/o
• Stroke (abrupt loss of function, known vascular RFs: age > 50, atherosclerosis elsewhere, htn, dm, hyperlimidemia, atrial fibrillation, smoking)
• CNS infection
• Hypoglycemia
• Meds, drug use/overdose/toxins
• Suggests sensory abnormality - e.g. central or peripheral nerve dysfunction
• Other metabolic: thyroid, hypocalcemia, other
• generalized etiology - e.g. deconditioning, poor nutrition, anemia, chronic advanced medical conditions, combinations etc
• myasthenia gravis (subacute, progressive, worse w/repetitive movement, ocular sx → double vision)
• tumor (progressive, focal deficits)
• bleeding (trauma, use of anti-coagulants)
• infection/abscess
• Tumor (known malignancy, progressive, pain)
• Bleeding (acute, use of anti-coagulants, trauma)
• Compression from boney encroachment (progressive, chronic pain)
• Cervical (arms, pain radiates along nerve distribution)
• Lumbar (legs, pain radiates along nerve distribution)
• Median nerve - carpal tunnel (pins/needles, thumb/index/middle/1/2 ring, worse in AM)
• other nerves - with sx consistent with nerves affected
• metabolic disorders (diabetes → distal findings first, longstanding, poor control)
• toxic exposures
• see fatigue
• stroke (other C/V RFs, acute, other focal neurological complaints)
• labrythitis (abrupt, worse w/movement, self limited, URI Sx prior)
• benign positional vertigo (acute, worse w/movement, no other neuro Sx, prior trauma, usually self limited)
• Meniere's Disease (tinnitus, waxes and wanes, unilateral, hearing loss)
• hypovolemia (bleeding, diarrhea, volume loss for any other reason, Sx provoked by standing, + orthostatic vital signs → vital.html#Blood )
• meds or toxins
• impaired sensory inputs when walking/standing (vision, hearing, peripheral neuropathy, muculoskeletal, other)
• Primary Neuro
• link to weakness
• peripheral neuropathy → numbness
• cerebellar d/o (ataxic gait, impaired fine motor fxn, difficult to understand speech)
• neuro muscular dz
• movement d/o
• visual problems
• generalized weakness
• deconditioning
• chronic illness
• link to fatigue
• MSK Disease (e.g. arthritis)
• cognitive disorders (dementia, delirium)
• medication side effects
• combinations of any
• migraine (recurrent, last many hours, severe, throbbing/pulsating, sometimes aura, assoc w/ N, V, light & sound sensitivity, unilateral; often seek quiet & dark places to lie down 'til resolves)
• tension (recurrent, bi or uni-lateral, dull, no migraine/other sx)
• cluster (recurrent, brief, severe, focused around eye/temporal area, assoc w/tearing/rhinorrhea)
• post concussive (hx discrete traumatic event, or hx recurrent events)
• chronic daily headache (headache 15d/m for 3m, represents transformation of a primary headache syndrome → typically migraine or medication overuse)
• Trauma - can cause concussion, bleeding, or swelling
• Subdural (older → assoc w/brain atrophy, mild (deceleration) to severe trauma, change in behavior/level of consciousness, acute to sub-acute)
• Epidural (assoc w/significant blunt trauma, rapid decline in level of consciousness - which can wax and wane)
• sub-arachnoid (acute and severe head ache, rapid decline in consciousness, "worst headache of life")
• Parenchymal (acute, loss of function → based on location)
• viral (acute, fever, head ache, neck pain, n, v, delirium)
• bacterial (acute, fever, head ache, neck pain, n, v, delirium)
• fungal (sub-acute, often assoc w/compromised states → hiv, cancer, fever, feeling poorly in general, sub-acute headache & neck pain, delirium)
• encephalitis (acute, headache, fever, systemically ill, deliirium)
• abscess (acute/subacute, headache, fever, loss of function based on location, progressive, delirium; reason for abscess → spread from adjacent site, AVM, PFO, neurosurgery)
• benign (sub-acute, loss of function based on location, confusion/change in personality, headache)
• primary (sub-acute, loss of function based on location, confusion/change in personality, headache; abrupt worsening if bleeding superimposed)
• metastatic lesion (sub-acute, loss of function based on location, confusion/change in personality, headache; abrupt worsening if bleeding superimposed, known primary w/tendency to met to brain → renal cell, breast, melanoma, lung)
• Aneurysm (acute headache if leaking, other localizing sx if pushes on a nearby structure, when leaks/ruptures → sub-acrachnoid bleed)
• AVM (acute or sub-acute, loss of function based on location, can have abrupt change if superimposed bleeding)
• temporal arteritis (older, acute, jaw pain w/chewing, Hx Polymyalgia, neck/shoulder aches, decreased vision, tender over temporal artery)
• Other vasculitides - suggested by hx/specific organ involvement: lupus, PAN, Wegeners, Takayasus, Churg-Strauss
• dural sinus thrombosis (acute, assoc w/hypercoaguable state or inflammation, can cause seizures and focal deficits, delirium)
• Meningitis (acute, neck pain, delirium, fever)
• Abscess (fever, head ache, delirium, focal neuro deficits)
• Toxoplasmosis (sub-acute, headache, confusion, fever, CD4 < 200 or untreated HIV, focal neruo deficits)
• HSV (similar to non-HIV +, causes encephalitis &rarr fever, confusion)
• Cryptococcus (CD4 < 50 or untreated HIV, sub-acute headache, fever, confusion)
• Cocci (CD4 < 250, headache, neck pain, lethargy, living in endemic area &rarr Southwest)
• TB (fever, sweats, weight loss, confusion, TB elsewhere, CD4
• Syphilis (can occur at any CD4 level, primary: genital ulcers , and secondary (rash, other systemic findings: generalized skin , hands , feet ; other sx and findings similar to non-hiv +, neurosyphillis &rarr gait problems, confusion, sensory deficits)
• Depression (recognizing that HA will not be the sole manifestation of depression)
• Eye related
• Strain (slowly progressive, worse with reading, glasses working less well, no red flags)
• Glaucoma (acute, eye pain, visual changes, eye redness, firm globe on palpation)
• Sinusitis (acute, post nasal drip, facial pain, nasal d/c, cough)
• Generalized viral or bacterial infections
• Systemic Hypertension (severe, though chronic htn is typcially well tolerated and asx; acute increases in BP beyond a threshold; or very very high values)
• carbon monoxide (winter months w/exposure to heaters in closed spaces/poorventilation, worse when in that environment → better outside, others w/similar sx who live/work in same place).

More Info About Endocrine Disorders: National Endocrine and Metabolic Diseases Clearinghouse

• Diabetes, hypo/hyperthyroidism, etc
• see under Genito-Urinary - Frequency
• see under General - Fatigue
• See under General - Weight loss
• See under General - Weight gain

Infectious Diseases

More Info About Infectious Diseases: National Institute for Allergy and Infectious Diseases and Centers for Disease Control

• acute or chronic infections, etc

Bacteria Gram Negative Organisms e coli (GNR, cause uti, also abdominal/pelvic abscesses; HO157 causes enteritis and HUS) klebsiella, enterobacter, serratia (GNRs, cause of urinary tract infection, also abdominal/pelvic abscesses; hospitalized patients → pneumonia, wound infection, uti) proteus (common cause of urinary tract infection, can contribute to stone formation; wound infection hospitalized patients) pseudomonas (lung infections in patients with bonchiectasis → CF, COPD, compromised pts; bacteremia in patients w/neutropenia, also abdominal/pelvic abscesses, wound infection in patients w/DM; wound and urinary infections hospitalized/compromised pts; osteomyeliitis; otitis externa in patients w/DM) neisseria meningitidis (GNC, meningitis; f, c, ha, n, v, sepsis) neisseria gonorrhea (GNC, urethritis; cervicitis/PID; if disseminated infectious arthritis) moraxella (GNC, otitis media; bronchitis in copd exacerbation; pneumonia in COPD) legionella (community acquired pneumonia, cough, sputum, f, c) haemophilus influenza (pneumonia, otitis media, epiglottitis, meningitis; much less common since widespread use of vaccine) HACEK organisms (endocarditis → typically sub-acute → f, c, malaise x weeks) salmonella typhi (relapsing daily fever x weeks, malaise, ha, chills, relative brady, related to poor sanitation → outbreaks, travel to endemic areas, gall bladder can act as reservoir) non-tyhoidal (diarrhea, n, v, cramps, often w/bloody stools) shigella (diarrhea, n, v, cramps, often w/bloody stools, typically self limited) campylobacter (diarrhea, n, v, cramps, often w/bloody stools, typically self limited) yersinia enterocolitica (diarrhea, f, c, cramps; typically self limited) pestis → plague (passed from rodents to humans by fleas or direct contact w/feces, rapid onset f, c, sepsis, pneumonia) helicobacter (stomach ulcers) pertussis (characteristic whooping cough; kids can have airway compromise; adults presents as persistent cough x weeks easily spread; vax of kids and re-vax of adults preventive) Other less common gram negatives vibrio cholera (toxin mediated profound watery diarrhea, related to exposure to unclean water sources, often s/p natural disasters → presents as epidemics) vulnificus (causes sepsis in hosts w/cirrhosis or otherwise compromised hosts, exposure via raw/under cooked shellfish; also skin infection if same hosts exposed via inoculation) francisella tularensis → tularemia (passed from dying wild animals to humans via ticks/insects, US Southeast and Rocky Mtns, causes skin ulcers, lymphangitis, f, c) brucella (ingestion of raw/uncooked dairy, not present in all countries, causes recurrent f, c, systemic sx, arthritis, other organ involvement) batonella henslae (caused by cat scratch, regional adenopathy w/in few weeks, fatigue) bacillary angiomatosis ( nodules on skin , resemble Kaposis Sarcoma , occurs in HIV infected or otherwise compromised pts) Gram positive organisms Cocci Staph aureus coag + ( cellulitis , skin abscess ; wounds; osteomyelitis via direct extension; arthritis; bacteremia with seeding of abnormal or artificial valves, joints or devices; virulent w/rapid destruction valves/death w/in hours/days; toxic shock; pneumonia following viral infection; toxin based food poisoning → n/v hours after exposure, others affected who ate same) coag - ( cellulitis , skin abscess ; bacteremia with seeding of abnormal or artificial valves, joints or devices, less virulent than coag +) mrsa ( cellulitis , skin abscess ; bacteremia with seeding of abnormal or artificial valves, joints or devices, can be hospital or community acquired; healthcare assoc pna) Streptococcus Group A (cellulitis/lymphangitis; skin abscess; erysipelas; throat infections → acute pain, f, adenopathy: pharyngeal erythema and d/c; impetigo; contribues to necrotizing fasciitis ; scarlet fever → high temp, rash, palatal petchiae, throat sx) Group B (endometritis, meningitis, bacteremia, neonatal infection) Group D → enterococcus (urinary tract infection, pelvic/abd abscess, wound/other infxn in chronically ill/hospitalized patients) Viridans (endocarditis → subacute w/sx f, c, malaise x weeks) pneumoniae (pneumonia, upper respiratory infections, meningitis; bacteremia if severe; increased risk if s/p splenectomy) Rods listeria (meningitis in old and young patients) diptheria (upper respiratory infection w/cough, f, sore throat, pseudo-membrane w/airway obstruction; uncommon now w/vax) anthrax (acquired from animal exposure or biological weapon; inhalation: cough, f, c,pneuonia sepsis; cuteaneous: ulcer to eshcar w/surrounding edema) Anaerobes (GN or GP) often associated with mixed/complex infections/abscesses of abdomen, pelvis, lung, mouth clostridium: GPR perfringes (most common cause food born diarrhea → undercooked meat, cramps, diarrhea, 6-18h after ingestion, resolves in 24h, other who ate same ill simultaneously; deep tissue infection contibuting to necrotizing faciitis ; contribute to abd/pv abscess; NEC in neonates) difficile (antibiotic associated colitis, can occur after any abx, cramps, diarrhea) tetani (exposure via contaminated wounds if unvax, 1w incubation,increased tone in jaw muscles, dysphagia, diffuse musle pain/spasams, airway compromise; uncommon w/widespread use vax) botulinum (food/wound born toxin, incubation 1-2d, rapid descending symetric paralysis staring w/cranial nerves, dizziness, dry mouth, visual sx, no sensory deficitis, aggitation, resp failure, death) bacteroides fragilis (GNR, contributes to abdominal/pelvic abscesses) peptostreptococus (GPC, lives in mouth, contributes to mixed oral/lung infxns/abscess) Other bacteria chlamydia trachomatis (urethritis, cervicitis/PID) pneumoniae (fever, upper resp sx, non-productive cough) psittacosis (spread by exposure to parrots & sometmes other birds, 1-2 week incubation; fever, cough, severe HA; other organ systems as well) mycoplasma pneumoniae (common cause CAP; acute f, c, cough, upper resp sx; not usually severe) nocardia (lives in soil, causes sub-acute pneumonia, also abscess/cellulitis/lymphangitis if direct inoculation) actinomyces (oral/neck/face slow growing abscess, often w/sinus tract development, can affectother organ systems as well) Viruses rhino, adeno (common cause of upper respiratory infxn, cough, nasal congetsion, sore throat, ear pain) influenza (common cause upper and lower respiratory infection, seasonal in North America oct to april, increase risk if no vaccination; abrupt onset of myalgias, arthralgias, fever, chills) more from CDC ) rotavirus, norovirus (common cause of acute enteritis: abrupt onset n, v, d, diarrhea; rota in partic kids enteroviruses (non-specific sx of f, c, aches; meningitis) coxsackievirus (myocarditis, pericarditis, hand/foot/mouth in kids f, malaise) polio - eradicated in US w/vaccine EBV → mononucleosis (incubation 4-6w, pro-drome 1-2w of fatigue and myalgias; then f, head/neck adenopathy, pharyngitis, hepatomegaly, splenomegaly) herpes simplex (past by sexual or oral contact; genital or oral herpes, encephalitis; fever or pain prior to appears vesicles ; resolves spont; can recur, can be congenitally acquired) varicella zoster ( chicken pox , shingles → dermatomal vesicles , pneumonia in setting severe chicken pox) Hepatitis A (acute liver infection, spread fecal/oral/ingestion contaminated food, can be epidemic; incubation 2-4w, n, v, abd pain, f, jaundice , icterus ; generally self limited) B (acute liver infection, incubation 3m; spread via sexual contact, vertical, shared needles, needle sticks in health care workers, unscreened blood transfusion: acute may cause f, c, jaundice , icterus ; may be sub-acute; 95% adults resolve, 5% go on to chronic hepatitis → risk cirrhosis, HCC) C (chronic hepatitis, acute infection generally not recognized, spread via needles, unscreened blood transfusion, cocaine inhaling tools, needle sticks in health care workers, vertical, sexual - rel difficult; 10-20% resolve; long term risk cirrhosis and HCC) HPV ( genital warts , peri-anal warts , years later causes cervical cancer, head/neck scc, penile scc) RSV (winter mos, cough, fever, typically affects infants and children) para-influenza (upper resp infection/croup, tracheobronchitis) parvo (most common ages 5-19, slapped cheek rash, also rash on arms, soles, palms; acute arthralgias/arthritis that can mimic RA; can cause acute hypoprolif anemia) CMV (retinitis/colitis/disseminated dz in patients w/HIV; systemic infection in patients 1-4m s/p transplant; normal hosts get mono-like symptoms: incubation 3-8 w, then f, c, malaise hepatomegaly, splenomegaly, fatigue x 4-6w; head/neck adenopathy & pharyngitis are rare) rabies (bite from infected animal → skunk, bat, squirrel, dog; incubation can be days to mos, f, ha, myalgias, arthralgias, hydrophobia, intermitent confusion/aggitation, sensitivity to sound/light; sx onset to death avg 4d) Hanta (rodent exposure; 3-4d f, myalgias, HA, n, v, abd pain; then rapidly progressive resp sx) West Nile (incubation 2d-2w; summer/fall in North America, fever, muscle aches, confusion, ha, stiff neck, rash, confusion → meningo-encephalitis) measels (uncommon w/vaccination, winter/spring in US, cough, f, malaise, conjunctivitis, runny nose, then rash, white spots on oral mucosa; complications include encephalitis, pneumonia) mumps (uncommon w/vaccination, f, myalgia, malaise, affects B parotids and testicles) rubella (uncommon w/vaccination, rash starts on face, fever, adenopathy; can be congenitally acquired) Fungi candida (common cause of fungal skin infection: tinea cruris , tinea pedis , vaginitis; worse/recurrent if immune-compromised) Coccidioidomycosis (south west US, higher risk if immune-compromised, sub-acute pneumonia/effusions, also arthritis, skin , seeding of other sites) aspergillus (pneumonia in compromised host, tissue invasive or fungal ball, invasive sinusitis in patients w/DM or otherwise compromised, can infect any organ; recurrent wheezing in normal hosts → ABPA) histoplasmosis (can be asx/mild and resolve spont; often see x-ray evidence prior infection lung, spleen w/o known past infxn; exposure to Mississippi & Ohio river valley; cough, fever; can cause resp/systemic illness in HIV+) mucor (invasive sinusitis, pneumonia in patients w/DM or otherwise compromised; cough, fever, HA, sinus pain) pneumocystis jerovecii (pneumonia in patients w/HIV; also in those compromised by long term steroid use) Mycobacteria tuberculosis (sub-acute, cough, hemoptysis, weight loss, sweats; can also infect GI/GU tracts, bone; increased risk if immune-compromised/hiv +) more from CDC MAC (HIV + cause of diarrhea; indolent lung infection in patients with bronchiectasis) MAI (diarrhea in patients w/HIV) M Marinum ( sub-acute skin infection , after exposure via fish tanks) M Leprae (slow, anesthetic macule, area of involvement spreads, direct nerve involvement, neuropathic pain and enlargement of involved nerve, Southeast Asia) Retrovirus (HIV) HIV (hiv risk factors → men who have sex w/men, unprotected intercourse, sex w/prostitutes, sex w/somone known hiv +, ivdu, transfusion w/unscreened blood, drug/etoh abuse, hx other sti's, health care worker's w/needle stick injury; risks of unusual infection increase as CD4 declines - see organ specific sx) more from CDC Spirochetes borrelia burgdorferi → lyme (endemic area north east, upper mid west, tick contact x 24-48h; inoculation days to weeks, then-->rash, f, c, aches; then arthralgias, heart block, CNS involvement; later still arthritis) more from CDC syphillis (sexual exposure, initially painless genital ulcer → heals 4-6w; weeks later non-specific rash , w/predilection for palms , and soles , condyloma around genital areas, mucous involvement, adenopathy; late manifestations yrs later affecting CNS, large blood vessels → aortitis, aneurysm) more from CDC leptospirosis (contract via exposure to rodent/wild animal feces; inoculation period several weeks; mild dz is self limited f, c, ha, n, v, musle aches, conjunctival injection; severe dz with hepatic and renal involvement, icterus ) Rickettsiae Rock Mtn Spotted Fever (exposure to tick, incubation 2d to 2w; can occur in most states in US, f, c, ha, arthralgias, then generalized rash - though not always, can be severe/fatal) human ehrlichiosis (often co-infection w/lyme, tick born, incubation ˜1w, f, ha, n, v, myalgias; often causes BM suppression) Parasites malaria (passed via mosquitoes, live in tropical climates: Southeast Asia, Africa; susceptibility increase if don't use proph abx; incubation 1-4w; recurrent high fevers, c, HA) toxoplasmosis (protozoa, carried in cat feces, healthy hosts not affected, in HIV + causes brain infection dc4 < 200 → headache, f, delirium, szr; pregnant women can pass in utero → congenital abnl) giardia (protozoa, spread via poor hygiene, contaminated water, drinking from ponds/streams, anal intercourse; many infected are asx; incubation 1-3w; non-bloody diarrhea, gas, burping) entamoeba hystolytica → amebiasis (protozoa, acquired via unclean water/poor sanitation, also anal intercourse; only 10-20% develop sx; incubation 2-4w; abd pain, bloody diarreha; occas liver abscess) trichinosis (roundworm, rare in US; from eating infected meat; abd pain, n, v, diarrhea; after 1-2w, muscle pain when migrate to muscles, rash, ha, n, v) ascariasis (roundworm, tropics/sub-tropics/SE US, eggs swallowed if contaminated soil ingested → eggs hatch in intestines → larvae enter blood stream → migrate lungs → mature & coughed up → swallowed → mature in intestines; cough, fever, sob, n, v, abd pain, impaired growth of children, sbo) hook worm (common world-wide, enter thru feet/skin if walk barefoot in soil w/infected feces → bloodstream → lungs → swallowed → intestines → blood loss → anemia, d) enterobiasis (pin worm, fecal oral, common in kids, cause nocturnal peri-anal itching) w bancrofti (tropics/sub-tropics, spread by mosquitoes, filaria invade lymphatis, after years → lymphedema from obstruction of channels) onchocerciass (causes river blindness, Africa/central-south America; spread by black fly; conjunctivits/keratitis, skin nodules) schistomiasis (south america, middle east, caribbean, africa: flukes, invade skin of swimmers, enter blood stream → live in portal/mesenteric veins; can cause cirrhosis after years; can live in bladder → SCC after years) cysticercosis (tapeworm, ingest eggs via infected beef that's undercooked; Mexico, Africa, Southeast Asia; eggs cross intestines, migrate to host muscles and brain, can cause seizures) echinococcus (worm; from cattle and dogs; in US and many other areas; eggs ingested by humans → travel to liver → cysts form & can cause RUQ pain → compress biliary tract → if rupture can cause anaphylaxis) Non-Infectious Malignancy - many cancers (e.g. renal, leukemia, lymphoma), with specific dx guided by localizing sx, careful exam and identification of risk factors Auto-immune - specific disorder based on other symptoms and findings - relatively uncommon (compared w/above) RA (sub-acute, persistent/progressive joint pain, tendency for bilateral involvement → MCPs hands , knees; warmth; redness; worse in am; women > men; fatigue) Lupus (sub-acute, female > male, black>white, sub-acute, fever and feeling poorly in general, rash on face, other system involvement → kidneys, brain) Familial Med Fevers (uncommon, associated w/cryptic abdominal pain, rash, arthritis, arthralgias, myalgias, recurrent fever) Still's disease (subacute, uncommon, rash , sore throat, arthralgias) Polymyalgia Rheumatica - PMR (sub-acute, age > 50, morning shoulder and hip aches, no findings on exam of joint inflammation) Giant Cell Arteritis (age > 50, often prior hx PMR, fatigue, headache, joint aches, visual loss) Other vasculitides Inflammatory bowel disease (sub-acute, recurrent or chronic diarrhea; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic sx; presentation can also be fulminant) Serum sickness (acute, symetric, additive/migratory, polyarthritis; myalgias, fever, rash; typically from rx to abx, or secondary to viral infxn → e.g. acute hep b; onset days to weeks after exposure) Endocrine Low testosterone (sweats but no fever, decreased libido, fatigue, errectile dysfunction) Menopause (sweats but no fever, age ˜ 50, irregular menstruation) hyperthyroidism (irritability, inability to sleep, diarrhea, palpitations, tremor, heat intolerance) adrenal insufficiency (weakness, n, v, skin darkening if central etiology) Meds: Dx based on r/o other causes and temporal link between initiation med and fever onset malignant hyperthermia → e.g. inhalational anesthetics - typically in OR or soon thereafter neuroleptic malignant syndrome → e.g. haldol, chlorpromazine (high fever, cramps, delirium, autonomic instability) many other meds - including broad range of abx Other DVT/PE (acute, cough, SOB, pleuritic, hemoptysis, unexplained unilateral leg swelling, RFs for DVT; Well's Criteria for DVT ; Well's Criteria for PE ) Musculoskeletal

More Info About Musculoskeletal Disorders: National Institute of Arthritis and Musculoskeletal and Skin Disorders

Comprehensive Muscuoskeletal Exam

• Degenerative joint disease/Osteoarthritis, Rheumatoid Arthritis, Lupus, gout, etc.
• Gonorrhea (hx sti, hx sexual activity, hx penile or cervical d/c)
• Staph or Strep (hx direct trauma w/inoculation of bacteria into joint, actue symptoms after joint surgery/aspiration, spread from systemic bacteremia, or spontaneous)
• Fungal (relatively uncommon, sub-acute, hx coccidiomycosis, exposure to endemic areas for cocci → Southwest)
• Spirochete (hx living in area endemic w/lyme, bull's eye type rash prior to joint pain)
• Gout (acute, worse w/movement, one or few joints - commonly great toe , male >> female, hx prior gout, evidence of tophi )
• Pseduogout (presentation similar to gout)
• Bacterial- secondary to bacteremia → very ill
• Parvo (symetric moderate joint inflammation, exposure to kids who harbor illness, self limited)
• Gout, psedogout - can affect a few joints simultaneously, though more commonly mono-articular
• RA (persistent/progressive; bilateral: MCPs hands , knees; warmth; redness; worse in am; women > men; fatigue; systemic Sx)
• Lupus (female >male, black>white, sub-acute, fever and feeling poorly in general, rash on face, other system involvement →kidneys, brain)
• Psoriatic (hx psoriasis, findings of psoriasis on exam )
• Serum sickness (acute, symmetric, additive/migratory, polyarthritis; myalgias, fever, rash; typically a rxn to abx, or secondary to viral infxn → e.g. acute hep b; onset days to weeks after exposure)
• Reactive arthritis (acute pain and swelling following infection elsewhere: GI (campylobacter, yersinia, salmonella, shiegella), STI (chlamydia); if eye and urethral sx →consider Reiters, most common in knees/feet/ankles, acute/sub-acute, age typically 20-40)
• Osteoarthritis (subacute/chronic, worse w/activity, slowly progressive, prior injury, wt bearing joints (knees, hips))
• Structure around/near the joint
• Bursitis (exam reveals absence of effusion, area of inflammation is over anatomic bursa , focal redness, warth, pain on touch)
• Cellulitis ( local redness , induration, pain, not restricted to a joint or anatomic bursa, not clearly worse w/movement)
• Teno-synovitis (worse w/active motion, over tendon)
• Muscle pain
• Other/non-joint related pathology - e.g. arthralgias from systemic illness, in which case exam of the joint is normal
• primary disorder
• extreme exercise
• Polymyalgia Rheumatica (age > 50, subacute, hips and shoulders, worse in AM)
• Fibromyagia (chronic, pain at multiple trigger sites, no other explanation found on exam and labs, fatigue, head aches)
• Meds/drugs → cocaine
• Referred from joint pathology
• Polymyostitis (associated with weakness)
• Systemic infection
• Local infection

Detailed exam

• Nerve root irritation from disc or DJD → "sciatica" (waxes/wanes, radiates down leg)
• spinal stenosis (older, slowly progressive, worse standing, radiates down B legs w/walking)
• Para-spinal muscles/Muscle spasm (acute, wax/wane, para-spinal area; pain on palpation)
• Spondylolisthesis (progressive, pain is focal w/o radiation, sometimes preceded by antecedent increase in activity, worse w/activity and better w/rest; pain sometimes worse on palpation over affected area)
• Sacro-iliac joint problems (pain over SI areas, sometimes assoc w/trauma, can be linked to inflammatory arthritides→Ank Spond)
• Spondyloarthroathies (onset 20s, better with activity, very limited range of motion)
• Fracture (trauma/mechanism of injury that could cause fx, osteoporosis, age > 50, pain on palpation)
• Cancer (known cancer with prediection for mets to spine → prostate, lung, breast; if not known cancer then symptoms suggestive of primary somewhere)
• Infection: Osteomyelitis/discitis (unremitting, known systemic infection → endocarditis, fever, chills, acute/sub-acute; pain on palpation over infected area;extension from skin/trauma; associated with foley catherization; spontaneous )
• Cauda equina (acute/sub-acute, bowel and/or bladder incontinence; weakness and numbness of legs)
• Multiple myeloma (fatigue, anemia, shortness of breath, fever, bleeding)
• Abdominal Aneurysm (age > 50, C/V RFs, abd sx w/radiation to back, if obese → non-specific abd pain on palpation; if thin, might be able to feel the aneurysm; severe VS abnormality from bleeding and hypovolemia if rupture)
• Renal stone (acute, severe, colicky, radiates towards abd/pv)
• Renal infection (acute, F, C, N, dysuria, urinary frequency)
• Posterior duodenal ulcer (severe, acute, boring/gnawing pain that radiates from epigastrium to back, n)
• pancreatitis (acute, N, V, ETOH abuse, gall stones)
• endocarditis (F, sweats, abnormal/prosthetic valves, systemic Hx, Hx bacteremia)
• viral syndromes

Detailed Exam

• Fracture (direct fall on knee or impact w/hard structure → dashboard))
• Patella dislocation (acute, prior hx dislocation, appears displaced lateral/medial on exam)
• ACL disruption (twisting injury, often non-contact, acute pain, audible pop, acute swelling from blood)
• Meniscal injury (twisting or contact, acute/sub-acute pain, hx meniscal injury, swelling hours to days later → slower accumulation blood)
• Infection (acute, worse w/movement, one or few joints, fever,\ chills)
• Gout (acute, worse w/movement, one or few joints - commonly great toe, male >> female, red/inflamed joint , tophi )
• pseudo-gout (acute, worse w/movement, one or few joints - commonly great toe, male >> female)
• Lupus (female > male, black>white, sub-acute, fever and feeling poorly in general, rash on face, other system involvement → kidneys, brain)
• Prepatellar (redness & swelling limited to directly over patella, hx chronic kneeling)
• Anserine (redness and swelling inferio-medial to knee)
• Cellulitis ( redness in skin , sometime pain to touch of skin but less w/range of motion joint, not anatomically limited to over knee)
• Osteoarthritis (subacute/chronic, worse w/activity, slowly progressive, prior injury, wt bearing joint, obesity)
• Meniscal injury (sesnse of instability/giveway, decrease ROM, locking, swelling)
• Ligamentous insufficiency (hx ligament injury, sense of give-way and pain when stress applied in direction that ligament typically check - eg. twisting)

Detailed Hand Exam

• Metacarpal fracture (striking closed fist against solid surface, pain over 4th/5th metacarpal
• Navicular fracture (pain over anatomic snuff box, persists despite negative xrays)
• Distal radial fracture (pain over distal radius)
• Fall with thumb abducted - Ulnar collateral ligament disruption (pain and swelling over MCP area, pain and weakness with grasping, laxity on exam )
• Extensor tendon disruption of finger (caused by sudden direct force jamming extended finger, pain, finger distal to dip rests in flexion, unable to extend)
• Sub-ungual hematoma finger (related to direct trauma distal aspect finger, pain, swelling, dark discoloration under nail from blood)
• Median nerve compression (chronic sx, affects thumb/2nd/3rd and 1/2 4th fingers, worse in AM, patient feels need to "shake out hands" to improve blood flow, weakness and atrophy late findings )
• Ulnar nerve compression (chronic, sx radiate down to 1/2 ring and index finger, often worse at night/in AM)
• Radial nerve compression (typically associated w/trauma at proximal humerus or prolonged compression in that area → intoxication and passed out x hours, unable to extend at wrist, numbness back of hand )
• Cervical nerve root irritation (pain radiates to fingers from neck, can be provoked by maneuvers that compress nerve roots at neck)
• RA (sub-acute, symmetric, worse w/movement, predilection for MCPs , worse in am due to gelling phenomenon → better w/use, pain if squeeze involved joints, feels spongy if palpate around joints from synovial inflammation, female > male, other joints as well)
• Infection (acute, symptoms localized to area that's infected, worse w/movement, red, warm, painful, local trauma as portal or systemic seeding; DIP infection )
• Gout (acute, red, warm, pain w/movement, hx gout elsewhere; MCPs , wrist )
• Nail area infection (paronychia) (acute, localized redness and swelling, pain at margin of nail )
• Soft tissue distal finger (felon) (acute, pain, warmth, redness, swelling most prominent on pulpy aspect of distal phalynx)
• Sub-ungual infection (beneath nail) (acute swelling, pain beneath nail, symptoms worse with nail pressure then with pressing on pulp)
• Tenosynovitis (extensor or flexor surface; pain with active extension or flexion of wrist or affected fingers, passive motion hurts less, sometimes associated w/penetrating trauma if secondary to infection → e.g. cat bite; redness, warmth and swelling over affected tendon)
• Cellulitis (acute pain, swelling, redness, warmth of the skin )
• Ganglion cyst (painless bump over dorsal or ventral aspect of wrist, not warm or colored, transilluminates as it's fluid filled, doesn't interfere with function )
• Nodules at PIP or DIP (firm, boney, non-tender, associated with OA )
• Other cysts or lipomas (slowly progressive, non-tender, not associated w/an underlying structure )
• Skin cancer (non healing, slow growing: Basal cell ; squamous cell , melanoma
• Dupuytrens contracture (focal thickening of palmar fascia, can interfere w/ability to extend fingers, non-tender, no inflammation, associated with diabetes, ETOH, and idiopathic )
• Trigger finger (finger stuck in flexed position w/inability to extend smoothly, then sudden give-way and able to move, slowly progressive to point where cant extend, sometimes tender, no redness or swelling)
• Osteoarthritis (slowly progressive pain at any joint, related to chronic wear and tear, can also have antecedent injury that damages joint, worse w/use, better w/rest, no redness or warmth, common at base of thumb → interferes with gripping/twisting)
• Extensor tendonitis of thumb (Dequervains) (sub-acute, pain at base of thumb's metarcarpal, worse with thumb extension, interferes with pinching/grasping, no warmth or redness, pain on palpation or provocative maneuvers )
• Trauma - with assessment for fracture based on mechanism of injury, site of pain
• Gout or pseudogout (acute, hx gout or pseudogout elsewhere)
• Infection (fever or systemic sx, trauma w/direct path of infection into joint, or systemic seeding)
• RA (sub-acute, persistent, symmetric, hx RA elsewhere, can be associated with nodules , worse in am due to gelling phenomenon → better w/use)
• Olecranon bursitis - non-infected (sub-acute, swelling at point of elbow, non-tender, no warmth or redness, doesnt interfere w/joint movement or function )
• Oelcranon bursitis - infected or otherwise inflamed (swelling at point of elbow, red, warm, tender to touch, able to still move elbow joint with minimal pain )
• Cellulitis (redness, swelling, tenderness in skin, not restricted to anatomic bursa, no evidence bursal fluid collection)
• Osteoarthritis (not common probably because not a load bearing joint and not prone to injury, worse with activity, chronic/slowly progressive, no warmth, redness or swelling)
• Lateral epicondylitis (chronic, pain over lateral aspect of elbow, associated with chronic/repetitive motion, no warmth or redness, worse w/wrist extension)
• Medial epicondylitis (chronic, pain over medial aspect of elbow, associated with chronic/repetitive motion, no warmth or redness, preserve range of motion of elbow, worse w/wrist flexion)
• Osteoarthritis (chronic, progressive, associated with obesity, worse with weight bearing and increased use, sometimes prior trauma)
• Fracture (hx fall or other high force injury)
• avascular Necrosis (sub-acute, progressive, pain w/weight bearing, hx underlying predisposing condition: ETOH, lupus, trauma, steroid use)
• labral injury (pain in front of hip/groin, worse w/flexing/rotating, sensation of catching/clicking, can be sports related)
• vascular (hx atherosclerosis, dull ache, worse w/activity, better w/rest)
• Infection (acute, pain w/any range of motion, warmth and redness, fever; direct extension from truama/surgery or spread from systemic infection)
• RA (known disease elsewhere, sub-acute, warmth/redness, pain w/ROM, symmetric, worse in morning)
• Non-infected (sub-acute, worse w/movement, pain on palpation of trochanter, pain w/resisted abduction of hip, limited warm/redness/swelling, preserved range of motion of hip)
• Infected (uncommon, pain over trochanter, redness, warmth and swelling over trochanter)
• Referred pain from back (patients will also typically have back pain, with radiating/electric shock type symptoms that travel from back area towards and below hip)
• Fracture (acute pain over affected bone(s)→ scapula, clavicle, humerus; sometimes obvious deformity, loss of function)
• A-C separation (fall directly on shoulder, pain over A-C, A-C deformity )
• Dislocation (most are anterior w/humeral head displaced forward out of gleno-humeral joint, significant force from behind that pushes humerus forward; combination of arm extended, abducted and externally rotated; deformity and extreme pain, no range of motion; person will often be holding arm (w/opposite hand) in slight abduction and ext rotation; can be recurrent, in which case hx prior dislocation)
• Rotator cuff tear (acute from fall or throwing injury; often chronic pain prior indicating partial tear)
• Osteoarthritis (slowly progressive process, hx trauma/injury to shoulder that set up the development of OA, loss of range of motion)
• Impingement/sub-acromial bursitis (sub-acute/chronic, worse w/arm overhead, pain at night, associated w/repetitive overhead activity like swimming)
• Labral tear (pain w/throwing, decreased velocity w/throwing of ball)
• Instability (sense that arm will pop out of joint when move in certain ways, hx prior dislocation)
• Biceps tendonitis (sub-acute/chroicanterior shoulder pain, worse w/flexion and supination, biceps rupture )
• Adhesive capsulitis (sub-acute to chronic; exam remarkable for decreased range of motion in all directions, sometimes antecedent injury that leads to cycle of decreased use → decreased ROM → decreased use; no warmth or redness)
• Rotator cuff tear and/or tendonitis (typically of supraspinatus, results from chronic overhead motion, resultant pain w/anterior movement, weakness; if complete tear, cant lift arm from side)
• Infection (acute, pain with any ROM, red , fever, hx prior procedure/injection that introduced infection
• Rheumatoid Arthritis (subacute/chronic, hx RA, B shoulder sx, worse in AM and better later in day w/use, other symmetric joint involvement-->MCPs hands, warmth, redness, decreased ROM)
• PMR (sub-acute, pain around shoulders and hips, age > 50, fever w/o other source, worse in AM, fatigue; non-specific pain around shoulder during exam,)
• R shoulder → subphrenic abscess around liver (detailed shoulder exam normal, abdominal symtpoms and pain on palaption)
• L shoulder → splenic infarct or abscess (LUQ pain, reason for embolic event to spleen → endocarditis)
• Cervical nerve root irritation (pain radiates from neck to shoulder and down arm; exam w/o evidence intrinsic shoulder pathology)
• Intra-thoracic pathology (heart attack → pain can radiate to L shoulder; aortic dissection → pain to L shoulder, PE → can radiate to either shoulder; in any of these situation, shoulder exam would be normal and patient should have other suggestive sx)

Mental Health

More Info About Mental Health: National Institute of Mental Health

Comprehensive mental status exam

• depression, anxiety, schizophrenia, etc
• depression (PHQ2 screen: little interest or pleasure in doing things; feeling down depressed or hopeless)
• -->PHQ-9 Depression Screen -->
• depression, substance abuse d/o
• Anxiety d/o, substance abuse, depression
• Assoc w/dementia, other - define with Mini Mental Status Exam (MMSE)
• Delirium (acute change from prior behavior → disorganized thinking, confusion; waxes/wanes, spectrum from somnolent to very agitated, more likely in elderly & those w/underlying cognitive problems like dementia, easier to identify those who are agitated then those who are somnolent)
• Infection anywhere -- the greater magnitude infection, the more likely delirium (site of infection identified by localizing sx and findings)
• Meds - in particular psychoactive (benzos, anti-psychotics, narcotics) - though could be any - often a result of combination of agents
• Toxins/over dose - cocaine, crystal, etc
• Severe metabolic derangements - hyponatremia, hypercalcemia, hypoglycemia, etc
• Severe organ dysfxn - liver, renal, cardiac, anemia, hypoxemia
• Severe pain, in particular if coupled w/any of above
• Primary neuro process - trauma, bleeding, infection
• Often combinations of the above
• Dementia (older, progressive, memory deficits, slowly progressive - define w/ comprehensive exam, SLUMS
• bipolar (cycling between periods of depression and mania → euphoria, risky behavior, racing thoughts, easily distracted, poor performance school/work, not sleeping, delusions)
• schizophrenia (age onset teens-30s,delusions, halucinations, hearing voices, disordered thought, disorganized behavior, social withdrawal)

Skin and Hair

More Info About Skin Disorders: National Institute of Arthritis and Musculoskeletal and Skin Disorders

• Without Scarring
• Andro-genetic
• Men (bi-temporal & /or posterior)
• Female → diffuse
• Hereditary (family hx)
• Alopecia areata (male or female, 20-50, circumscribed patches or generalized, spontaneously re-grows)
• Telogen effluvium → diffuse loss (w/severe systemic, chemo or other meds, hiv, pregnancy; generally regrows after insult)
• Local trauma → chronic pullin
• Local fungal infection (patches, flaking)
• Malnutrition
• With Scarring
• Hereditary or developmental d/o
• Necrotizing Infection - bacterial, fungal
• Cancer of the skin or mets
• Burns, XRT, Caustic agents, severe trauma
• Sarcoid, lupus, lichen
• cancer, psoriasis, alopecia, etc
• Infection, inflammatory, other
• epidermal cyst
• basal cell cancer (telangiectasias, pearly w/rolled edges, growing, non-healing, central depression, sun exposed areas)
• squamous cell cancer (non-healing, growing, crusted, firm, sun exposed areas)
• melanoma (asymmetry, bleeds, irregular borders, non-homogeneous pigment, grows, doesn't heal)
• chronic advanced illness (kidney, liver, hiv), meds (prednisone, chemotherapy), chronic skin infection
• eczema (chronic, waxes/wanes, hands/arms/face)
• contact dermatitis (acute, following contact w/something)
• elevated bilirubin → jaundice (advanced liver disease)
• chronic renal dz, other

Finally, we’ve developed the on-line Web App Digital DDx , which provides a much more extensive diagnostic support tool. ROS questions are provided, along with a clickable tree of diagnoses to aid in the interpretation of responses. It also contains many other features that highlight the connections between organ based symptoms and specific disorders.

• History of Present Illness

Review of Systems

• Past Medical History
• Physical Examination
• Essential Differential Diagnosis
• Essential Immediate Steps
• Test Interpretation
• Relevant Testing
• Test Results
• Treatment Orders
• About the Case

Reccurent Headaches in a 31-yr-old Woman

• General : She denies weight change and fevers but does feel generally fatigued.
• Skin : Noncontributory
• HEENT : She has noted occasional bilateral nontender swelling of the neck associated with the headaches. She denies any vision changes, lacrimation, nasal congestion or discharge, tinnitus, earache, discharge from the ear, sore throat, tooth pain, and facial flushing.
• Pulmonary : Mild shortness of breath sometimes accompanies her palpitations and neck swelling, but she has no other respiratory symptoms.
• Cardiovascular : Patient reports palpitations that occur during headaches. Palpitations last from a few minutes to several hours and resolve spontaneously. She has no chest pain with the palpitations or at other times. Her exercise tolerance is normal when she is asymptomatic.
• Gastrointestinal : Patient complains of nausea associated with the headaches but no vomiting. She denies abdominal pain, and her bowel movements have been normal except for one episode in which she felt as though she was going to faint while straining on the toilet.
• Genitourinary : She has occasional left flank pain but no dysuria or hematuria. Last normal menstrual period was 2 wk ago; duration and flow were normal.
• Musculoskeletal : She has no muscle aches, joint pain, or stiffness.
• Neurologic : She reports a single episode of transient right-sided arm weakness and altered sensation that followed one of the headaches. The weakness lasted < 1 h and resolved completely. Patient denies photophobia, phonophobia, and neck pain. She has had no previous head or neck injury.
• Psychiatric : She reports episodes of feeling suddenly anxious even when sitting relaxed in the evening.

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Review of Systems

The Review of Systems (ROS) is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing. The Centers for Medicare and Medicaid Services (CMS) recognizes 14 systems:

• Constitutional symptoms (i.e. fever, weight loss, vital signs)
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Hematologic/Lymphatic
• Allergic/Immunologic

There are a couple of document guidelines for the ROS that you should be aware of when it comes to your patient’s medical record. A ROS obtained during an earlier encounter does not have to be documented again if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by describing any new ROS or noting there has been no change in the information. The physician will also have to document the date and location of the earlier ROS in the present encounter. Another guideline is that a staff member may document the ROS in the medical record as long as there is evidence that the provider reviewed their documentation.

You have to reference the date of the last ROS if referring to this in your present note. You cannot state review of systems unchanged from last visit, the date is needed.

Looking at the History Table, you will note that there are three levels to choose from:

• A “problem pertinent” ROS inquires about the system directly related to the problems(s) identified in the HPI. Documentation needs to include the positive responses and pertinent negatives for the system related problem.
• An “extended” ROS inquires about the system directly related to the problems(s) identified in the HPI and a limited number of additional systems.  Documentation needs to include the positive responses and pertinent negatives for two to nine systems.
• A “complete” ROS inquires about the system directly related to the problems(s) identified in the HPI plus all additional body systems. At least ten systems need to be reviewed.  Those systems with positive responses and pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is allowed. 

Note the wording above for each of the three levels ROS needs to be directly related to the problem.

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• History of Present Illness

Review of Systems

• Past Medical History
• Physical Examination
• Essential Differential Diagnosis
• Essential Immediate Steps
• Test Result 1
• Test Interpretation
• Relevant Testing
• Test Results 2
• Treatment Orders
• About the Case

Chest Pain in a 62-yr-old Man

• General : Patient has generally been feeling fine. Good energy level. Sleeping well.
• Skin : No new rashes or skin lesions.
• HEENT : No vision changes, ear pain, nasal symptoms, or sore throat.
• Pulmonary : No dyspnea with exertion; no cough.
• Cardiovascular : No palpitations, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema.
• Gastrointestinal : No abdominal pain, nausea, or vomiting. Appetite is normal.
• Genitourinary : Noncontributory
• Musculoskeletal : No recent injury or immobilization.
• Neurologic : Noncontributory
• Psychiatric : Noncontributory

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2.9 Review of Body Systems

A body system review asks focused questions related to overall health status and body systems such as cardiac, respiratory, neurological, gastrointestinal, urinary, and musculoskeletal systems. See “ Chapter Resources A ” for a sample health history form that contains brief questions according to body systems. Nurses often incorporate review of system questions into the physical examination of each system. For example, while listening to bowel sounds in the abdomen, a nurse often inquires about the patient’s bowel pattern. Additional focused assessment questions related to each body system are found in each assessment chapter of this book.

Nursing Skills - 2e Copyright © 2023 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Review of Systems Template Examples

REVIEW OF SYSTEMS:  No fever, no chills, no weight change. Ocular:  No drainage, no blurred vision. HEENT:  No sore throat, earache, or congestion. No neck pain. COR:  No chest pain. No palpitations. Lungs:  No shortness of breath or cough. GI:  No nausea, no vomiting, no diarrhea, no constipation, no anorexia. GU:  No dysuria, frequency or urgency. No hematuria. No vaginal discharge or vaginal bleeding. Musculoskeletal:  No joint pain or swelling or edema. Skin:  No rash or itching. Psychiatric:  No anxiety, no depression. Endocrine:  No polyuria or polydipsia.

REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. The patient denies headache, nausea, vomiting, or visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough and hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation, or diarrhea. Urinary:  The patient has normal urination. Musculoskeletal:  The patient denies muscle weakness, pain, or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  The patient denies recent URI, fever, chills, weight loss or night sweats. No headache, visual symptoms, stiff neck. Had no associated neck, arm, jaw pain or pressure today. Does have chronic back and body aches, which are diffuse and varying in site from day to day. Denies significant abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. No swelling of her hand, feet or face. No neurologic symptoms. No rash. No lymphadenopathy. A 14-point review of systems is otherwise negative.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  No fever. No chills. No dizziness. No weakness.

EYES:  No pain, erythema, or discharge. No blurring of vision.

ENT:  No sore throat, URI symptoms. No epistaxis. No tinnitus.

CARDIOVASCULAR:  No chest pain. No palpitations. No lower extremity edema.

RESPIRATORY:  No shortness of breath, cough, pain with respiration, pleuritic chest pain. No hemoptysis. No dyspnea. No paroxysmal nocturnal dyspnea.

GASTROINTESTINAL:  Normal appetite. No nausea, vomiting, diarrhea. No pain. No bloating. No melena.

GENITOURINARY:  No frequency, urgency, nocturia. No hematuria or dysuria.

MUSCULOSKELETAL:  No arthralgias or myalgias.

INTEGUMENTARY:  No swelling. No bruising. No contusions. No abrasions. No lymphangitis.

NEUROLOGIC:  No headache. No neck pain. No numbness or tingling of the extremities. No weakness.

PSYCHIATRIC:  No confusion.

ENDOCRINE:  No fatigue. No weakness. No history of thyroid, diabetes or adrenal problems.

HEMATOLOGICAL:  No bleeding. No petechiae. No bruising.

ALLERGIES:  No asthma. No urticaria.

REVIEW OF SYSTEMS:  The patient denies any neck, arm, jaw, back, chest pain or pressure symptoms that are new. No palpitations. No dizziness. No sweats. Denies significant headache, visual symptoms, stiff neck. No recent URI, fever, chills, weight loss or night sweats. No abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. Has had no shortness of breath. Denies any swelling of his hands or face or his right lower extremity. No trauma. No skin lesions. No lymphadenopathy. A 14-point review of systems otherwise negative.

REVIEW OF SYSTEMS:  Without fever, chills, weight loss, or night sweats. No URI symptoms, no headache, visual symptoms, stiff neck, no trouble walking, talking, weakness, numbness, tingling of extremities other than the above noted left arm symptoms today. Had no other recent chest pain, pressure. No swelling of his hands, feet, face or symptoms suggestive of CHF. No abdominal pain, change of bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms, testicular pain, ureteral discharge. No rash, no lymphadenopathy. A 14 point review of systems is otherwise negative.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient denies any fever or chills.  HEENT:  No headaches, sore throat.  Positive for left otalgia.  CARDIOVASCULAR:  No history of palpitation or arrhythmia.  RESPIRATORY:  History is negative for cough, productive sputum.   GASTROINTESTINAL :  History is negative for nausea or vomiting.  All other systems essentially negative.

REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. Head:  The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough or hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary:  The patient has normal urination. The patient has amenorrhea for last 3 years. Musculoskeletal:  The patient denies muscle weakness. The patient denies pain or joint stiffness. The patient denies restriction of range of motion. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  No fevers, chills, lightheadedness, fainting, or weight loss. HEENT:  No visual problems, sore throat, or nasal congestion. CARDIOVASCULAR:  No chest pain, palpitations, or orthopnea. RESPIRATORY:  No cough, shortness of breath or hemoptysis. GASTROINTESTINAL:  See HPI. GENITOURINARY:  No flank pain, dysuria or hematuria. ENDOCRINE:  No polyuria or polydipsia. HEMATOLOGIC:  No bleeding disorder. SKIN:  No rashes or jaundice. All other systems reviewed and are negative.

REVIEW OF SYSTEMS: States she has a headache every day, very dull headache. Does not take anything for it. It only lasts for an hour or two and she is not sure what precipitates the headache. She feels that she does not know how much fluid she takes. Denies any caffeine use and she states these headaches are not new. She has had them for as long as she can remember. No lightheadedness or dizziness. No chest pain or shortness of breath. No cough, wheeze. No fever. No heartburn symptoms. No nausea or vomiting. She is happy with her weight. No constipation. No diarrhea. No genitourinary symptoms. No skin changes, rashes or lesions. Depression: She shrugs her shoulders and states she is not depressed and she denies anxiety. She says she sleeps well at night most of the time.

REVIEW OF SYSTEMS: The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient denies itching rashes, sores and bruises. The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck: No complaints. Respiratory: The patient denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: The patient denies chest pain and palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: The patient complains of frequent urination. No blood in urine. No urine retention. No pain during urination. The patient usually goes to the bathroom during the night 2 to 3 times, during the daytime 3 to 4 times. Musculoskeletal: The patient denies muscle weakness. Denies pain, joint stiffness. The patient complains of low back pain radiating to the left lower extremity with numbness of the left lower extremities and episodes of weakness of the left lower extremities. The patient has restriction of range of motion at the lumbosacral spine on flexion and extension. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  Denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient complains of itching, rash on both lower extremities, located on anterior shins. No bruises and no ulceration. The patient denies headache, nausea, vomiting, visual changes. Eye, ears, nose, sinuses, mouth, throat and neck: No complaints. Respiratory: Denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: Denies chest pain or palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: Has normal urination. Musculoskeletal: Denied muscle weakness. No pain or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  There is no history of fever, weight loss or cough. CNS:  No history of vision changes, seizure or weakness. ENT:  No history of congestion, postnasal drip, sore throat or hearing changes. Respiratory:  No history of shortness of breath, wheezing or chest pain. Cardiovascular: No history of chest palpitations or arrhythmias. GI:  No history of nausea, vomiting, diarrhea or abdominal pain. GU:  No history of dysuria, frequency or vaginal discharge. Musculoskeletal:  Positive for ankle pain, joint pain, joint edema as well as right lower extremity edema with some tenderness in the calf area.

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Review of systems medical transcription phrases and words for mts, privacy overview.

Critical Concepts

Meditations on critical illness

The systems-based approach

One of the idiosyncrasies of critical care is the practice of breaking down each patient  by systems.

Most specialties document the review of systems and physical examination in this manner, organizing the large quantity of resulting data into categories such as “Cardiovascular,” “Respiratory,” and “Musculoskeletal.” Only critical care, however, tends to present its assessments and plans in the same style.

Why? Simply put, critically ill patients are complicated. A typical ward patient may be admitted with only one or two problems that need addressing. In contradistinction, an ICU patient usually has one or two primary, driving problems—but also a host of other concomitant issues that complicate or emerge from them, such as mechanical ventilation, stress ulcer prophylaxis, and electrolyte abnormalities. This litany of mentionables would quickly lead to an unwieldy “problem-based” assessment and plan, but it’s worse than that: without a universal framework to make sure you address every angle of a multi-faceted patients, it’s easy to miss things. Rather than only considering whatever problems spring to mind, you need a set of standard categories that forces you think comprehensively.

A systems-based approach is the flexible Swiss Army Knife of critical care. When applied regularly and consistently, it becomes ingrained into one’s very mental model of the patient, like a medical Sapir-Whorf hypothesis. More mundanely, it can be invoked when writing notes, rounding, presenting a patient, or signing them out.

How does it work? There are many variations on the theme, and it can be adjusted for your needs. Different folks list different systems, and certainly place them in differing orders; indeed, it is  de rigueur to give one’s favorite system primacy, so the CCU tends to place  Cardiovascular first, the MICU starts with  Respiratory , and the NCCU favors  Neurologic . It hardly matters, but develop your own preferences, and keep it consistent; that way you’ll be able to activate your personal template from memory without a second thought.

Here’s an approach to get you started.

• Pain, analgesia, and sedation (although some prefer to make a separate category for this)
• Encephalopathy of any variety, including delirium
• Neurological injuries
• Mobilization and activity

Cardiovascular

• Shock, pressors , and inotropes
• Arrhythmias
• Heart failure
• Acute coronary syndromes and troponinemia

Respiratory

• Respiratory failure
• Mechanical and non-invasive ventilation, including extubation plans
• Pneumonitis and pneumonia
• Pneumothorax, COPD, asthma, etc.
• Pulmonary toileting (e.g. incentive spirometry) and SpO2 goals

Gastrointestinal

• Diet, enteral feeding, TPN—or NPO status
• Stooling issues such as diarrhea or constipation, and bowel regimens
• GI bleeds or surgical issues involving the GI tract (ostomies, bowel trauma), and hardware (NG tubes, PEGs, rectal tubes)
• Hepatic pathology such as transaminitis, cholecystitis, and cirrhosis
• Stress ulcer prophylaxis, if not mentioned elsewhere

Renal/Genitourinary

• Fluids, including fluid balance issues (e.g. overload and diuresis), IV fluids, and urine output
• Electrolytes, including imbalances worth mentioning. (Note: some providers like to make a separate “FEN” category that lumps together Fluids, Electrolytes, and Nutrition.)
• Acid-base issues, such as metabolic acidosis
• Renal and GU pathology such as hematuria, renal calculi, and most commonly, acute kidney injury

Hematologic

• Cell line dyscrasias, including anemia, thrombocytosis, and thrombocytopenia
• Coagulopathies, such as DIC
• Bleeding issues, although these can sometimes fall into other categories as well
• Thrombosis, such as DVT and PE. DVT prophylaxis can be discussed here if not placed elsewhere
• Glucose control
• Thyroid derangements, adrenal insufficiency, and other hormonal imbalances

Infectious Disease

• Active infections, either suspected (leukocytosis, etc) or proven
• Microbiology results: blood/sputum/urine cultures, gram stains, lab assays ( C difficile PCRs, Legionella urinary antigen, etc.)
• Antibiotics: current, prior, and planned durations

Other things

Depending on the clinical setting and provider preference, other “systems” may be useful to include. These might include  Trauma , Surgical , Musculoskeletal , or  Orthopedic . Some like an  Integumentary or  Skin system.

Systems where nothing needs to be said can simply be documented with a remark such as “No active issues.”

In addition to the above, some non-physiologic but practical categories are often worth establishing, such as:

• Prophylaxis : DVT and stress ulcer prophylaxis.
• Access : Current intravenous access, such as peripheral IVs, central lines, and arterial lines. This can also be expanded to a list of all lines/tubes and other hardware, such as chest tubes, Foleys, drains, etc. It is also wise to document when such things were placed, and whether or not it was sterile.
• Social : Social issues, such as the name and contact information for the primary decision-maker, or family conflict and other dilemmas.
• Finally, it is common to end with the ultimate question:  Disposition . Where will the patient go? Will they stay in the ICU, be downgraded to another service, or even be discharged?

Worth the while

While this approach to patient care may seem obsessively thorough, it is thoroughness—rather than the excitement of resuscitation or the bloody drama of procedures—that may be the truest hallmark of critical care.

Certainly, there are providers, or whole teams, whose practice and culture do not cleave to this method. They round haphazardly, identifying whichever problems catch their eye and addressing them ad hoc. In their notes, they mention only the most noticeable issues and omit the others. When presenting a patient they only discuss the immediate.

Their approach saves time. It saves time by forgetting important things. And that is not good critical care.

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14-Point Review Of Systems Template

Streamline patient assessments with our 14-Point Review of Systems Template as a valuable screening tool for early detection and diagnosis of various health conditions.

By Telita Montales on Jul 23, 2024.

Fact Checked by Ericka Pingol.

What is a 14-point review of systems?

A 14-point review of systems (ROS) is a comprehensive approach healthcare practitioners use to systematically assess a patient's overall health status and identify potential medical concerns or symptoms across various body systems. This structured approach ensures a thorough evaluation, reducing the likelihood of overlooking significant issues.

The 14-point ROS assesses each organ system to identify potential medical concerns. It typically covers the following areas:

• General: Assessing for symptoms such as fever, chills, fatigue, weight changes, or overall malaise.
• Head, ears, eyes, nose, and throat (HEENT): Evaluating issues related to headaches, dizziness, vision problems, hearing difficulties, ear pain, sinus pain, or sore throat and discomfort.
• Respiratory: Exploring symptoms like cough, wheezing, shortness of breath, or chest pain associated with breathing.
• Cardiovascular: Assessing for chest pain, palpitations, edema (swelling), or other heart-related concerns.
• Gastrointestinal (GI): Investigating abdominal pain, nausea, vomiting, diarrhea, constipation, or changes in appetite or bowel habits, a GI review of systems or GI ROS can help diagnose conditions like gastrointestinal infections and digestive disorders.
• Genitourinary: Evaluating urinary frequency, urgency, incontinence, or discomfort related to the genitourinary system.
• Musculoskeletal: Exploring joint pain, muscle weakness, back pain, or other musculoskeletal issues.
• Neurological: Assessing for headaches, dizziness, numbness, tingling, or other neurological symptoms.
• Psychiatric: Evaluating mental health concerns, such as depression, anxiety, or changes in mood or behavior.
• Endocrine: Investigating symptoms related to hormone imbalances, such as heat or cold intolerance, excessive thirst, or hunger.
• Hematologic/lymphatic: Evaluating for easy bruising, bleeding, or swollen lymph nodes.
• Allergic/immunologic: Assessing for allergic reactions, skin rashes, or immune system disorders.
• Integumentary (skin): Examining skin lesions, rashes, or changes in moles or nails.
• Sleep: Evaluating sleep patterns, disturbances, or excessive daytime sleepiness.

Systematically reviewing each system allows healthcare practitioners to identify potential areas of concern and gather important information about the patient's chief concern that may assist in making an accurate diagnosis and developing an effective treatment plan (Phillips et al., 2017).

Do note that the 14-Point Review of Systems is sometimes called the Constitutional Review of Systems. Either one is commonly referred to as just Review of Systems .

14-Point Review Of Systems Template Example

Cardiovascular review of systems

The cardiovascular review of systems is a crucial component of the overall patient assessment process. It focuses specifically on evaluating the health and function of the heart and blood vessels. This comprehensive review aims to identify any potential cardiac or vascular issues that may require further investigation or management (Hagan & Hagan, 2023). A Cardiovascular Review of Systems Template can be a valuable tool during this process. It is important to follow up on any positive responses during the cardiovascular review of systems to further define the core dimensions of the symptom in question.

When conducting a cardiac review of systems, healthcare practitioners typically explore the following areas:

Chest pain, also known as angina, can be a significant symptom of underlying cardiovascular conditions, such as coronary artery disease, myocardial infarction (heart attack), or aortic dissection. It's essential to inquire about the location, severity, duration, and any factors that may exacerbate or alleviate the pain.

Palpitations

Palpitations refer to an abnormal awareness of one's heartbeat, which can indicate arrhythmias or other cardiac disorders. Patients may describe their heart as "racing," "fluttering," or "pounding."

Shortness of breath

Dyspnea, or shortness of breath, can be a symptom of various cardiovascular conditions, such as heart failure, valvular disorders, or pulmonary hypertension. It's important to assess the severity and timing of the symptom and any associated factors.

Fatigue and exercise tolerance

Assessing a patient's fatigue and exercise tolerance level can provide valuable insights into the cardiovascular system's ability to meet the body's demands. Reduced exercise tolerance may suggest underlying cardiovascular issues.

Through a review of systems, cardiovascular concerns can be subject to further diagnostic testing, such as electrocardiograms (ECGs), echocardiograms, or stress tests, to establish an accurate diagnosis and develop an appropriate treatment plan.

Musculoskeletal review of systems

The musculoskeletal review of systems (ROS) is crucial in patient evaluation. It concentrates on assessing the condition and functionality of the skeletal structure, joints, and muscles. This thorough review aims to identify any potential musculoskeletal problems or disorders that may necessitate further examination or treatment.

During a musculoskeletal ROS, the Musculoskeletal Review of Systems Template typically investigates the following areas:

Joint pain is a common musculoskeletal complaint and can be indicative of conditions such as osteoarthritis, rheumatoid arthritis, gout, or joint injuries. It's crucial to inquire about the location, severity, duration, and any factors that may exacerbate or alleviate the pain.

Muscle weakness or tenderness

Muscle weakness or tenderness can be a symptom of various musculoskeletal disorders, such as myopathies, muscle strains, or neurological conditions affecting the muscles. Healthcare practitioners should assess the distribution and severity of the weakness or tenderness.

Bone pain can be a sign of conditions affecting bone health, such as fractures, bone tumors, or metabolic disorders. The ROS musculoskeletal aspects should inquire about the location, severity, and duration of the pain and any associated trauma or other relevant factors.

Arthritis or rheumatoid arthritis

Arthritis, including rheumatoid arthritis, is a common musculoskeletal disorder characterized by joint inflammation, pain, and stiffness. It's crucial to assess the specific joints affected, the duration and severity of symptoms, and any associated factors, such as morning stiffness or joint deformities.

The review of systems for musculoskeletal areas helps healthcare practitioners identify potential areas of concern and determine the need for further diagnostic testing, such as imaging studies or laboratory tests, to establish an accurate diagnosis and develop an appropriate treatment plan.

How does it work?

Healthcare practitioners can follow these steps to make the most out of this resource:

Step 1: Patient interview

The process begins with a comprehensive interview, where the healthcare provider discusses each of the 14 systems with the patient. This conversation aims to uncover any symptoms, concerns, family history, or changes in health that the patient may have experienced.

Step 2: Systematic review

The healthcare provider then methodically reviews the organ systems in the template. This step involves asking specific questions based on the patient's chief concern and noting any positive or negative responses that indicate potential health issues of diagnostic significance.

Step 3: Accurate documentation

Recording all the patient's responses accurately in the template is crucial. This documentation is part of the patient's medical record and is essential for future reference and ongoing care.

Step 4: In-depth analysis

After completing the review, the healthcare provider analyzes the information to identify patterns, potential health issues, or areas requiring further investigation. This analysis is critical in forming a differential diagnosis and planning subsequent steps.

Step 5: Determining follow-up actions

Based on the review's findings, the healthcare provider decides if additional diagnostic tests, referrals to specialists, or other follow-up actions are necessary. This step is crucial in ensuring the patient receives appropriate and timely care.

What do the results mean?

The systems review results offer a comprehensive and nuanced understanding of a patient's health status. These results are pivotal in guiding the subsequent medical decisions and interventions.

Positive findings

Positive ROS results indicate symptoms or issues in specific systems. These findings are critical for healthcare providers as they can signal underlying health conditions that may require immediate attention or further diagnostic evaluation. For example, a positive finding in the cardiovascular system could suggest issues like hypertension or heart disease, necessitating a more in-depth cardiac assessment.

Negative findings

Conversely, negative findings, indicating the absence of symptoms in the reviewed systems, play a crucial role in the diagnostic process. They help exclude certain medical conditions, narrowing down the potential causes of the patient's presenting symptoms. This systematic elimination is key to formulating an accurate diagnosis.

Comprehensive health overview

The collective data from our Free 14 Point ROS provide a holistic view of the patient's health. This all-encompassing perspective is essential for creating a targeted and effective treatment plan, ensuring that all health aspects are considered and addressed.

Implications for patient care

The results from the ROS are instrumental in shaping the patient's healthcare journey. They inform the healthcare provider about the areas that require immediate attention and those that are stable, thereby aiding in prioritizing medical interventions.

Hagan, S. & Hagan, A.F. (2023). The review of systems and the physical exam. In: Wong, C.J., Jackson, S.L. (eds) The patient-centered approach to medical note-writing. Springer, Cham. https://doi.org/10.1007/978-3-031-43633-8_12

Phillips, A., Frank, A., Loftin, C., & Shepherd, S. (2017). A detailed review of systems: An educational feature. The Journal for Nurse Practitioners , 13 (10), 681–686. https://doi.org/10.1016/j.nurpra.2017.08.012

Commonly asked questions

To document a review of systems (ROS), the healthcare provider should systematically review a checklist of body systems and ask the patient if they are experiencing any symptoms related to each system. The provider should then document any positive or pertinent negative findings for each system reviewed. This is typically done by using a standardized template or form that lists the various body systems.

The standard 14 reviews of systems provide a comprehensive evaluation of the body's major organ systems and physiological functions, including constitutional (e.g., fever, weight changes), eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin), neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic factors.

The review of systems (ROS) cardiac exam evaluates the patient's cardiovascular health and function. During this part of the ROS, the healthcare provider will typically ask the patient about any symptoms related to the heart and circulatory system.

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A systemic enquiry (also known as a systems review) involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system are shown below.

Systemic symptoms

Systemic symptoms to screen for include:

• Night sweats
• Weight change

Cardiovascular symptoms

Cardiovascular symptoms to screen for include:

• Palpitations
• Pre-syncope
• Peripheral oedema

Respiratory symptoms

Respiratory symptoms to screen for include:

• Haemoptysis
• Pleuritic chest pain

Gastrointestinal symptoms

Gastrointestinal symptoms to screen for include:

• Appetite change
• Weight loss
• Abdominal pain
• Abdominal distension
• Changes in bowel habit: constipation, diarrhoea, steatorrhoea, melaena, hematochezia

Genitourinary symptoms

Genitourinary symptoms to screen for include:

• Changes in urine output or colour: oliguria, polyuria, anuria, dark urine, haematuria
• Infective symptoms: urinary frequency, dysuria, flank pain, offensive discharge, pelvic pain
• Bladder control symptoms: urinary urgency, urinary incontinence
• Obstructive symptoms: terminal dribbling, nocturia
• Uraemic symptoms: fatigue, nausea, anorexia, pruritis

Neurological symptoms

Neurological symptoms to screen for include:

• Visual symptoms: blurred vision, changes in colour vision, sudden loss of vision, floaters
• Headache: unilateral headache, bilateral headache, thunderclap headache
• Motor or sensory disturbance: muscle weakness, numbness, paraesthesia
• Loss of consciousness including seizures

Ear, nose and throat symptoms

Ear, nose and throat symptoms to screen for include:

• Hearing loss/tinnitus
• Facial pain
• Persistent nasal discharge
• Odynophagia

Musculoskeletal symptoms

Musculoskeletal symptoms to screen for include:

• Bone and joint pain
• Muscular pain

Dermatological symptoms

Dermatological symptoms to screen for include:

• Skin lesions
• Skin colour changes

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• Introduction

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way. [1] [2] [3]

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record. [4] [5] [6]

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below.

This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.

Chief Complaint (CC)

The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

• Examples: chest pain, decreased appetite, shortness of breath.

However, a patient may have multiple CC’s, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all of their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis.

History of Present Illness (HPI)

The HPI begins with a simple one line opening statement including the patient's age, sex and reason for the visit.

• Example: 47-year old female presenting with abdominal pain.

This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
• Alleviating and Aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?

It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than include excessive detail.

• Medical history: Pertinent current or past medical conditions
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient's family.
• Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Review of Systems (ROS)

This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.

• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, decreased right shoulder range of motion

Current Medications, Allergies

Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often. 

• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days

This section documents the objective data from the patient encounter. This includes:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.

A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.

This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.

List the problem list in order of importance. A problem is often known as a diagnosis.

Differential Diagnosis

This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

• Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Repeat for additional problems

This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:

• State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative
• Therapy needed (medications)
• Specialist referral(s) or consults
• Patient education, counseling

A comprehensive SOAP note has to take into account all subjective and objective information, and accurately assess it to create the patient-specific assessment and plan.

• Issues of Concern

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order. For instance, rearranging the order to form APSO (Assessment, Plan, Subjective, Objective) provides the information most relevant to ongoing care at the beginning of the note, where it can be found quickly, shortening the time required for the clinician to find a colleague's assessment and plan. One study found that the APSO order was better than the typical SOAP note order in terms of speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Re-ordering into the APSO note is only an effort to streamline communication, not eliminate the vital relationship of S to O to A to P.

A weakness of the SOAP note is the inability to document changes over time. In many clinical situations, evidence changes over time, requiring providers to reconsider diagnoses and treatments. An important gap in the SOAP model is that it does not explicitly integrate time into its cognitive framework. Extensions to the SOAP model to include this gap are acronyms such as SOAPE, with the letter E as an explicit reminder to assess how well the plan has worked. [7] [8] [9] [10]

• Clinical Significance

Medical documentation now serves multiple needs and, as a result, medical notes have expanded in both length and breadth compared to fifty years ago. Medical notes have evolved into electronic documentation to accommodate these needs. However, an unintended consequence of electronic documentation is the ability to incorporate large volumes of data easily. These data-filled notes risk burdening a busy clinician if the data are not useful. As importantly, the patient may be harmed if the information is inaccurate. It is essential to make the most clinically relevant data in the medical record easier to find and more immediately available. The advantage of a SOAP note is to organize this information such that it is located in easy to find places. The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow.

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Disclosure: Vivek Podder declares no relevant financial relationships with ineligible companies.

Disclosure: Valerie Lew declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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46 Free Review of Systems Templates (+Checklist)

Healthcare providers in the USA use a technique called Review of Systems (ROS) for obtaining the medical history of patients. This technique involves the use of a review of systems template and it’s often formatted as an element of an admission note that covers specific organ systems. It focuses on the subjective symptoms based on patients’ perceptions.

Table of Contents

• 1 Review of Systems Templates
• 2 What is a complete review of systems?
• 3 Review Of Systems Examples
• 4 The importance of a review of systems template
• 5 Review Of Systems Questions
• 6 What is included in the review of systems?
• 7 Review Of Systems Checklist
• 8 Applying a review of systems template
• 9 Review Of Systems Cheat Sheets
• 10 The difference between a review of systems and a history of present illness

Review of Systems Templates

What is a complete review of systems?

According to the 1995 guidelines for medical documentation, there are 10 systems that constitute a complete ROS needed for Level 5 visits. When you review all of the systems with patients, you need to use documentation like a review of systems checklist.

However, there are those who don’t follow the guidelines strictly. In such a case, they may need documentation of 10 individual systems when they don’t think there is an indication that the systems got reviewed. There are also those who don’t trust EHR systems because they group responses on a review of systems cheat sheet and make it appear that you’re getting 10 when actually, it’s fewer than that.

Review Of Systems Examples

The importance of a review of systems template

The definition of a review of systems template by the Evaluation and Management Documentation Guidelines is that “it is an account of body systems obtained through a series of questions seeking to spot signs and symptoms that the patient may experience or has experienced.” Consider these points that show the importance of a review of systems cheat sheet or template:

• The review of systems questions are typically conducted verbally by a physician or the staff through a patient form to find out the patient’s total problem. The process includes an explanation of why there is a need for additional testing, examination, and possible treatment options.
• The review of systems example may focus on the systems directly related to the issues pinpointed in the medical history of the patient’s present illnesses or any other body systems. You can present ROS questions using any format and should include a patient questionnaire form too.
• You may also include elements of the history of present illness (HPI) in the review. However, you should know that is a difference between the symptoms and signs shared by the patient in the HPI and those you acquire from the review of systems checklist. For one, the ROS is very precise. Here, there is always a distinct element of both the separate system review and the HPI.
• The elements of a review of systems example typically reference the signs and symptoms where you would consider both negative and positive comments. Auditors of the review watch for indicators when the medical staff or physician asks questions to the patient.
• The review of systems questions are to be medically required in order to get a complete ROS when the patient comes in for the first time. Some doctors also consider this document medically necessary to repeat the complete review for each follow-up.

Review Of Systems Questions

What is included in the review of systems?

A review of systems template is an inventory of the body systems acquired through inquiries with the purpose of identifying signs or symptoms the patient experiences. There are a total of 14 systems recognized by the Centers for Medicare and Medical Services:

• Allergic/Immunologic
• Cardiovascular
• Constitutional symptoms
• Ears, nose, mouth, throat
• Gastrointestinal
• Genitourinary
• Hematologic/Lymphatic
• Integumentary
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory

When it comes to a patient’s medical record, there are several guidelines that you must follow. For instance, one of the key guidelines state that there’s no need for re-documentation if the ROS acquired during the initial encounter shows evidence that the doctor performed a review and updated the patient’s information.

You can document the review process and the updated information by describing if there was is a new review of systems template. You can also note that there hasn’t been any change in the patient’s information. Another guideline that you need to remember is that any member of the staff may document the ROS in medical records as long as evidence exists that the physician performed a review.

You must indicate the date of your review of systems checklist if you refer to it in your most current notes. You cannot say that the ROS remains unchanged from the previous visit without providing a date. If you also use a History Table, you can choose from the following levels:

• A ROS that’s “problem pertinent” inquires about the system that’s directly related to the issues indicated in the patient’s HPI. Documentation should include the pertinent negatives and positive responses for the system-related problems.
• A ROS that’s “extended” inquires about the system that’s directly related to the issues indicated in the HPI along with a few of the body systems. The documentation must include the pertinent negatives and positive responses for 2 to 9 systems.
• A ROS that’s “complete” inquires about the system that’s directly related to the issues indicated in the HPI along with all of the body systems. You should review at least 10 systems and provide individual documentation for those systems with pertinent negatives and positive responses.

Take note of the wordings you use for each of the levels mentioned above. That way, your ROS questions can be directly related to the patient’s problems.

Review Of Systems Checklist

Applying a review of systems template

You can also consider a ROS as a list of questions arranged according to organ system. It’s designed to reveal disease and dysfunction. This is a very important document as you can use it in a number of ways:

• As a tool for screening for each patient that the clinician encounters.
• Ask ROS questions only to patients classified under a specific risk category. For example, reserving questions are only for determining occult diseases of the prostate of men aged 50-years-old and above.
• To better establish the most probable causes of a present symptom as described by the HPI section. For example, doctors can ask patients experiencing chest pains detailed pulmonary and cardiac ROS questions.

So, what is the best way to use a review of systems cheat sheet? It’s best used as a screening tool for broad applications. When you use it this way, the following statements would hold true:

• The questions to ask would reflect a range of important and common clinical conditions.
• These disorders could go undetected if the patient wasn’t prompted specifically.
• Identifying these conditions has a positive impact on mortality or morbidity.

Unfortunately, there is little evidence that supports these assumptions except for the few very specific screening tools. In fact, even the positive responses to an ROS screening aren’t very clear in their significance. These might even create more problems by creating additional questions and low-value testing results to make the matters complex.

Because of this, many clinicians are in-favor of a more thoughtful and targeted application of ROS questions based on specific patient characteristics like sex or age and risk factors like history of diabetes to vascular ROS questions. This approach is more revealing and efficient. The more experience you gain, the more you can make informed decisions about how to use the ROS into your strategies for patient care.

Review Of Systems Cheat Sheets

The difference between a review of systems and a history of present illness

In summary, the review of systems template is an inventory of body systems obtained through questions needed to find out identifying signs and symptoms that the patient experiences or has experienced. Then there are the three levels of a ROS that we had already gone through: the problem-pertinent ROS that involves the review of one system, the extended ROS that involves the review of 2 to 9 systems, and the complete ROS where the documentation should indicate the review of 10 or more body systems.

Although ROS and HPI can have similarities, the former differs from the latter because it includes queries related to the body systems. Here are some points that explain the difference between the two:

• Documentations of ROS must show that the physician asked a question to the caregiver or the patient. In cases where the notes don’t have their own ROS section, you should search for specific terms that indicate that the caregiver or patient answered the questions the provider asked.
• In the determination of whether to consider a history element as either an HPI or a ROS, give the credit to ROS but only if the provider did pose the question. You should only count each word or phrase should once, otherwise, you would do what’s known as “double-dipping,” where you would count something under both ROS and HPI.
• You can meet the documentation requirements for a complete ROS only if all pertinent negatives, positive responses, and a statement that includes the words “all,” “complete” or “remainder” get documented.
• Always remember that you can gather ROS through the questions asked either through a questionnaire or through verbal communication. Do not count a word or phrase under both HPI and ROS. If it appears that the information got obtained through a question asked, then count it as a ROS.

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Using systems thinking to envision quality and safety in healthcare

Stalter, Ann M. PhD, MEd, RN; Mota, Altagracia EdD, MSN, RN, OCN

Ann M. Stalter is an associate professor at the Wright State University College of Nursing and Health in Dayton, Ohio. Altagracia Mota is a manager for clinical learning at Montefiore Medical Center, Montefiore Learning Network in Bronx, N.Y.

The authors have disclosed no financial relationships related to this article.

Consider these evidence-based strategies to empower clinical nurses by utilizing Quality and Safety Education for Nurses competencies and systems thinking to improve outcomes.

A vision for safe quality care has been acknowledged since the days of Florence Nightingale, who recognized the link between nursing practice and outcomes. 1 In 1998, nurses identified the significance of practice errors on poor patient outcomes, and the National Database of Nursing Quality Indicators ® was established by the American Nurses Association to monitor how patient outcomes were related to unit-level nursing care. 1 The Institute of Medicine report, To Err is Human , highlighted human error as causing nearly 98,000 deaths and over 1 million injuries in U.S. hospitals. 2 The report offered opportunities for improving healthcare through total system transformation. The Robert Wood Johnson Foundation answered the call with Quality and Safety Education for Nurses (QSEN) to develop minimum standards for safe nursing practice. 3 Once standards were established, national nursing education credentialing bodies responded by requiring that QSEN competencies and systems thinking be integrated into program curricula. 4,5

After over a decade of deliberate transformation attempts, system-related errors were still being identified as a primary cause of death in the United States, translating to over 400,000 preventable deaths. 6 So, why haven't QSEN and efforts to develop systems thinking resulted in improved safety outcomes? Anecdotal evidence suggests that QSEN competencies and systems thinking aren't well integrated into practice settings. This article seeks to increase awareness of administrative and educator roles in empowering clinical nurses to understand the impact of their actions on patient and organizational outcomes using QSEN competencies and a systems thinking approach.

Defining roles

All nurses are leaders, educators, and care providers. Nursing position descriptions formalize nursing roles according to work settings. In this article, nurse leaders can be organizational directors or unit-level managers. Educators are defined by clinical instruction, often referred to as nursing professional development specialists. Clinical nurses are those who provide care within practice settings such as acute, long-term, home, or ambulatory care.

What are the QSEN competencies?

The six QSEN competencies—patient-centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement, safety, and informatics—have recommended, specific knowledge, skills, and attitudes that all nurses should exhibit for safe practice. Having these skills will assist nurses to continuously improve the quality and safety of the healthcare systems in which they work. Utilizing QSEN as a guide, nurses are able to redesign the content and context of how they deliver nursing care to ensure high-quality, safe care. 7 The competencies, developed at the prelicensure and graduate level, have been integrated into most nursing program curricula. However, more effort is needed to bridge these competencies to practice settings.

What's systems thinking?

Systems thinking isn't new to nursing. Most nursing theories contain systems thinking “where the whole is more than the sum of the parts.” 8 A person's interaction with his or her environment comprises a whole-person system, which is healthy based on a balance of inputs, throughputs, and outputs; nurses fits into the schema at the whole-person level. 9 The dynamic state of the whole-person system can ultimately influence global health. (See Figure 1 .) An analogy of a pebble dropping into a pool of water exemplifies how one nurse's actions can influence the greater whole. 10

Nurses can use systems thinking to view how caregiving decisions and actions have an overall impact on organizational health outcomes. Systems thinking is a process of self-awareness in which the nurse knows boundaries specific to clinical reasoning, personal effort, reliance on authority, and awareness of interdependencies. 11 Nurses can choose to mobilize change for the good of the whole system, based on experience and foresight. Nurses who display strong leadership behaviors can lead changes in practice and adherence to performance standards. 12 Systems thinkers are those who have an acute awareness of the current system, an appreciation for behind-the-scenes patterns and structures, a willingness to challenge systems and boundaries despite existing hierarchies, and an understanding of how system relationships are linked to system improvements. 12

Influence on practice

QSEN is on the brink of adopting a new systems-based practice competency for which nurses need to have basic knowledge about the healthcare system to create optimum health benefits for patients/families, peers, and organizations. 13 Systems thinking competencies reinforce nurses' roles in safety and quality improvement. 13 At minimum, nurses employing systems thinking and systems-based practice should be able to understand interrelationships among nursing, the nursing work unit, and organizational goals. They're encouraged to solve problems encountered at the point of care and appreciate their roles in identifying work unit inefficiencies and operational failures. 14 Nurses must be able to take action to address potential or ongoing quality and safety concerns. They need to be active participants in monitoring, admitting to, reporting, investigating, and resolving near misses, errors, and systems breakdowns involving communication, supplies, medication, equipment, finances, and technology.

Strategies to increase awareness

How can nurse leaders and educators empower clinical nurses to understand the impact of their actions on patient and organizational outcomes using QSEN competencies and systems thinking? More important, how can clinical nurses envision the ripples or waves they make across the healthcare system as being influential in positive patient outcomes? The following evidence-based strategies envision an improved practice reality and expand on published ideas recommended for nursing professional development and leadership. 15

Patient-centered care

Nurse leaders working at the unit or system level can use a variety of strategies to increase awareness of QSEN competencies and systems thinking among clinical nurses. These strategies include promoting relationship-based care by providing caring, healing environments; removing barriers that inhibit clinical nurses' abilities to be healthy, alert, and present with their patients; and promoting inclusion of patient involvement in health and treatment plan discussions. 16-18 Nurse leaders can utilize managerial expertise to allocate human, financial, and clinical resources based on unit needs and in alignment with the organization's mission and vision. 19,20 We need to promote and sustain patient–centered models of collaborative practice, such as interdisciplinary rounds, huddles, and/or primary nursing models. These structures provide nurses with complete autonomy in managing patient care and modifying practice to accommodate patient needs. 19

To influence patient-centered care, nurse educators can encourage self-health principles, champion patient-centered models, and instruct on ways to alleviate pain and suffering during staff education programs. 21 Nurse educators can teach staff members how to individualize patient care plans and empower patients to participate in treatment modalities. 22 Also, they can incorporate QSEN competencies into orientation assessments and evaluation tools. 23,24

Teamwork and collaboration

Closed-loop communication, identified leadership (at the senior and clinical level), and trust among team members have been identified as being essential to effective teamwork. 25 In today's healthcare system, patient care teams are challenged by expectations of specialized skill sets, value-based demands on performance, and complex environments with challenging workloads. Such challenges may impact team functioning and relationships. Incivility among team members in these situations has also been documented. 25

Nurse leaders can address these challenges through role modeling teamwork and collaboration, and by fostering open communication, mutual respect, and shared decision making. 20 Our support of teamwork building tools, such as TeamSTEPPS or I-PASS, may provide guidance to teams. TeamSTEPPS is used to minimize risks associated with handoffs among providers and across the care continuum, promote interdisciplinary communication of safety concerns, and build collaborative relationships. 26,27 I-PASS, a refined mnemonic for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver, is used to standardize handoffs and prevent errors. 26

At the organizational level, nurse leaders can establish collaborative relationships with public health, academic partners, and professional organizations. 20 We can advance the establishment of dedicated education units, in which the partnership between academic institutions and healthcare organizations provides an enhanced learning and clinical environment for nursing students. 28 This model offers educational support through a preceptor model experience; students can apply theory to practice while being immersed in the clinical environment and partnered with RNs. 29

To promote effective teamwork and collaboration, nurse educators can support the need for interprofessional immersion in clinical education. 30 Interprofessional education is a growing expectation of many professional organizations. 31,32 Educators can design interprofessional continuing-education programs that incorporate tools, such as TeamSTEPPS, with high-fidelity, interdisciplinary clinical simulations. 26 They can promote an interdisciplinary patient-centered culture by using educational programs to reinforce the role of team members in delivering safe and effective care. 33 Educators can also partner with leaders to establish interprofessional dedicated education units as part of the inpatient infrastructure. 34

EBP is the current driving force behind high-quality care delivery. Current evidence is integrated with individualized patient care needs and clinical expertise to design practice. 35 However, practice changes can lead to change fatigue, and nurse leaders and educators may struggle with addressing this side effect of EBP. Promoting change from the bottom up helps address change fatigue. 35 Clinical nurses do better with change when they're the ones initiating it. Putting processes in place and educating nurses on EBP will facilitate their active participation in practice changes.

Nurse leaders can integrate EBP by building an organizational culture that supports best practice and provides opportunities to enhance clinical nurses' EBP competencies. 35 In that process, nurse leaders share unit goals and organizational outcomes aimed at delivering EBP. 20 We can role model EBP by fostering a healthy work environment and minimizing change fatigue. 36,37

To integrate EBP, nurse educators can infuse the Alliance for Continuing Education in Health Professions National Learning Competency Area 1, which is the “use of evidenced-based adult and organizational learning principles to improve employee performance into continuing education programming.” 38 Nurse educators can advocate for the adoption of EBP throughout the nursing unit and organization by educating nurses on EBP skills, such as critical appraisal and translation of research findings into practice. 39,40 If nurse educators serve as experts at the national level in formulating practice guidelines, they can incorporate best evidence with clinical expertise and patient/family preferences in the delivery of optimum care. 3,41

Quality improvement

To enhance quality improvement, nurse leaders can employ error prevention strategies by continually monitoring outcomes and completing root cause analysis when errors occur, including clinical nurse input. 42 During rounding and/or in staff meetings, nurse leaders can share error prevention data to improve patient outcomes and promote an interprofessional approach to quality improvement and system processes. 3,43

Nurse educators can use data to evaluate and impact the effectiveness of continuing-education activities and programs. They can educate nursing staff on various quality/process improvement models in the utilization of outcomes data to improve care delivery. Educators can provide clinical nurses and students with opportunities to share EBP projects on the unit. They can also share unit-based EBP and quality improvement projects in staff meetings and during continuing-education programs, and/or by creating meaningful dashboards. 44

Nurse leaders can adopt high-reliability goals, such as standardized processes; safety checks; empowered decision making (authority migration); open, transparent communication; and collaborative, interprofessional teamwork. 45 We can also address the potential for errors by discouraging and putting policies/processes in place that minimize disruptions during high-risk situations, such as blood transfusions, surgical or invasive procedures, needle use, and medication administration/reconciliation, and by advocating for the use of technologies that monitor and control for errors, such as two-identifier systems for bar coding, I.V. medication pumps, and wander alarms. 46-48 Nurse leaders can implement 15-minute safety (adverse event) huddles as a way to reduce errors. 49 If errors occur, lead root cause analyses using the “Five Why's” strategy to determine causes and mitigating factors. 50 Leaders set the stage for clinical excellence by implementing a just culture that's intolerant of recklessness but works to resolve system-based errors in a collaborative, nonpunitive manner. 51,52 To prevent practice errors, nurse leaders can facilitate clinical nurses in establishing personal goals aimed at patient safety and error mitigation. 53

To promote safety, nurse educators can provide continuing-education programs geared toward educating clinical nurses about high-risk potential for errors. 46,47 They can also provide onboarding and ongoing education on safety measures to ensure proper patient identification. 48 At the organizational level, they can offer expertise during participation in root cause analysis using a clinical event investigation approach to determine causes and mitigating factors of errors. 50 They can facilitate the implementation of interprofessional education regarding open disclosures, collaborative review, and error and near-miss management. 54 Educators can also help clinical nurses by promoting self-reflection and peer review of clinical practice. 53,55

Informatics

Nurse leaders can advocate for the incorporation of evidence-based technologies and informatics. Enriched technologies may include electronically accessible clinical decision-making algorithms, clinical practice guidelines, and access to web-based resources. 56 Nurse educators can provide continuing education on modern technologies that sustain safe patient care and clinical judgments. 57 They can also support the roll-out of these technologies, serving as experts or liaisons between technology specialists and clinical staff.

Systems thinking

To implement systems thinking, nurse leaders can promote professional configurations, such as interprofessional collaborations, academic-clinical practice partnerships, and shared governance. 34,58,59 We can champion organizational structures of empowerment in which nurses have the opportunity, resources, and information to provide high-quality care; serve as a liaison or be a voice between the organization and clinical staff; promote staff understanding of local actions that impact organizational goals; and demonstrate how organizational goals drive local actions, impacting systemwide accountability for efficient, safe, quality care. 60-62 Lastly, nurse leaders can advance systems thinking through infrastructure redesign by integrating QSEN concepts into orientation, job descriptions, evaluations, or promotion criteria.

Nurse educators can implement evidence-based interventions that produce expected results for nurses and the organization, such as incorporating interprofessional education and education on hospital-acquired infection guidelines. They can educate staff on how to approach quality care delivery as the first step toward positive patient and organizational outcomes. Educators can emphasize the nurse's role in utilizing available organizational resources and processes to provide safe, efficient patient-centered care. They can approach the practice of continuing education from a systems thinking perspective, recognizing that the healthcare team is part of a complex system, and incorporate individual, group, and governance leadership competencies into onboarding and continuing-education programs. 38,63,64

A primary role

Providing high-quality, evidence-based, patient-centered care is a primary role of clinical nurses. Both nurse leaders and educators serve as facilitators to clinical nurses as they collaborate to improve care. This article provides a variety of evidence-based strategies for all nurses, at all levels, to consider when using QSEN competencies and systems thinking to improve outcomes.

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