ICM ROS flashcards

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ICM ROS flashcards
2012-02-25 11:34:23
review systems ICM

review of systems flashcards for ICM 3
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  1. General
    • Have you had any fever?
    • Have you had any chills?
    • Have you had any (night) sweats?
    • Have you had any weight loss or weight gain?
    • Have you been tired or fatigued?
  2. Dermatologic
    • Have you noticed a rash or skin lesion?
    • Does it itch or burn?
    • Have you had any changes in moles (size, color, border irregularity)?
    • Have you had any changes in hair texture?
    • Have you had any changes in nails?
  3. Head & Neck
    • Have you had any headaches? Where?
    • Have you had any neck pain?
    • Have you noticed any neck masses or “swollen glands”?
    • Have you had any neck stiffness?
    • Have you had any dizziness or lightheadedness?
  4. Ear
    • Have you had any hearing loss?
    • Do you use hearing aid(s)?
    • Have you had any ear pain or earaches?
    • Have you had any ringing in the ears (tinnitus)?
    • Have you had any discharge/blood/pus from the ears?
  5. Nose
    • Have you had any nasal discharge? What color?
    • Have you had any nose bleeds (epistaxis)?
    • Have you had any sinus pains or pressure?
    • Have you had any post-nasal drip?
  6. Throat & Oral Cavity
    • Have you had any sores in your mouth?
    • Have you had any tooth or gum problems?
    • Have you had a sore throat?
    • Have you noticed any hoarseness?
    • Do you wear dentures?
  7. Eyes
    • Have you had a change in vision?
    • Do you use glasses or contact lenses?
    • Have you had any double vision (diplopia)?
    • Have you had blurred vision?
    • Any redness of your eyes?
    • Any discharge from your eyes?
    • Any excessive tearing or dryness in your eyes?
    • Have you had any trauma to your eyes?
  8. Breast
    • Have you noticed any lumps/masses?
    • Have you had any breast pain or tenderness?
    • Have you had any discharge from the nipple?
    • Do you have any “swollen glands” under your arms?
    • Do you perform monthly self-exams on your breasts?
  9. Pulmonary
    • Have you had a (new/different) cough?
    • Have you brought up any phlegm? What color?
    • Have you coughed up blood (hemoptysis)?
    • Have you had pain with breathing (pleuritic pain)?
    • Have you had shortness of breath?
    • Have you had any wheezing?
  10. Cardiovascular
    • Have you had any chest pain?
    • Have you been short of breath?
    • *with exertion (dyspnea on exertion)
    • *while lying flat (orthopnea)
    • *suddenly while sleeping (paroxysmal nocturnal dyspnea)
    • Have you had any palpitations?
    • Have you had any swelling in legs or feet (edema)?
    • Have you had any pain in the calves while walking (claudication)?
  11. Abdominal
    • Have you had any difficulty swallowing (dysphagia)?
    • Have you had pain on swallowing (odynophagia)?
    • Have you had any heartburn? (Characterize it further)
    • Are you having any abdominal pain?
    • Have you had a loss of appetite (anorexia)?
    • Have you had any nausea?
    • Have you had any vomiting?
    • Have you had any diarrhea?
    • Have you had any constipation?
    • Have you noticed a change in bowel habits?
    • Have you had any black, tarry stools (melena)?
    • Have you had any bloody stools (hematochezia) or bright red blood per rectum (BRBPR)?
    • Have you noticed a change in the caliber of stool size?
    • Have you noticed your skin or eyes turning yellow (jaundice)?
    • Have you had hemorrhoids?
    • Have you noticed any easy bleeding or bruising?
  12. Genito-Urinary
    • Have you had to urinate more frequently?
    • Do you feel the urge to urinate more often (urgency)?
    • Have you had any pain or burning on urination (dysuria)?
    • Have you noticed any blood in urine (hematuria)?
    • Have you had any problem with loss of urine or bladder control (urinary incontinence)?
    • Do you wake up at night to urinate (nocturia)? How often?
    • Have you had a change in urine color or odor?
    • Males:
    • *Do you have difficulty starting your stream?
    • *Have you noticed any lesions on your penis?
    • *Have you had any penile discharge?
    • *Have you had any problems achieving or maintaining an erection?
    • *Have you noticed any scrotal or testicular masses?
  13. Gynecological
    • Describe the frequency, regularity, discomfort and heaviness of menses.
    • Have you any change in the discomfort/pain with menses?
    • Have you had spotting between menses, or any post-menopausal bleeding?
    • Have you had any “hot flashes”?
    • Have you noticed vaginal dryness?
  14. Sexual History
    • Are you sexually active? Have you noticed a change in your libido?
    • Have you noticed any changes or problems in your sexual functioning?
    • Has illness (if applicable) affected your sexual functioning?
    • Are you using condoms to prevent disease?
    • Are you using birth control - what type?
    • Are you in a monogamous relationship?
    • For men:
    • *Have you had any problems developing or maintaining an erection?
    • *Have you had any trouble having an orgasm?
    • For women:
    • *Have you had pain during intercourse?
    • *Have you had difficulty having an orgasm?
    • *Have you had problems with lubrication?
    • Have you had any concerns about getting a sexual disease or AIDS?
    • Have you had any other questions or concerns about this subject?
  15. Musculoskeletal
    • Have you had any pain in your joints? Which ones?
    • Have you noticed any joint or muscle stiffness?
    • Have you had any joint swelling? (Which joint?)
    • Have you noticed any muscle weakness?
    • Have you had any muscle tenderness?
    • Have you had any back pains? (Upper back?Lower back?)
  16. Neurological
    • Have you had any numbness (paresthesias)? Where?
    • Have you had any tingling (dysesthesias)? Where?
    • Have you had any problems with your memory?
    • Have you had any headaches? Where?
    • Have you noticed any dizziness (Vertigo)?
    • Have you had any problems with tremors (shaking)?
    • Have you had any episodes of blacking out (syncope) or loss of consciousness?
    • Have you had any problems with unsteadiness or balance?
  17. Psychiatric
    • Have you had any problems with anxiety?
    • Have you had any problems with depression?
    • Ask about symptoms of depression (SIGECAPS).
    • Do you have any:
    • *difficulty getting to Sleep or waking up early (insomnia)?
    • *loss of Interest in doing things (anhedonia)?
    • *feelings of Guilt?
    • *lack of Energy, fatigue?
    • *problems with Concentration?
    • *loss of Appetite (anorexia) or increase in appetite?
    • *problems with slow thinking or moving (Psychomotorslowing)?
    • *thoughts of Suicide?
    • Have you seen people or things that others did not see? (Hallucinations)