ROS

  • REVIEW OF SYSTEMS:
    • Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?
    • Constitutional:
      •  
      • fevers, 
      • rigors, 
    • ENT: 
      • rhinorrhea,  otalgia, sore throat
      • as noted in HPI
    • Eye:
      • vision grossly intact
      • as noted in HPI
    • Cardiac:
      • chest pain, 
      • LE swelling, 
      • no unilateral LE swelling
      • as noted in HPI
    • Pulmonary:
      • shortness of breath, 
      • cough, 
      • as noted in HPI
    • GI:
      • abdominal pain, 
      • nausea, 
      • vomiting, 
      •   BRBPR, dark tarry stool, 
      • diarrhea
      • as noted in HPI
    • GU:
      • no dysuria,
      • no discharge, 
        •  male specific:
          • no testicular pain, 
        • female specific: 
          • no abnormal vaginal bleeding, 
      • as noted in HPI
    • Neuro:
      • no recent severe headache outside of normal headaches per patient, 
      • no recent ALOC, 
      • moves all 4 extremities without any clear focal deficits,
      • Focused Neurological Exam:
        • CN II-XII intact,
        • vision grossly intact, 
        • PEERL, 
        • EOM intact, 
        • strength symmetric intact at major flexion and extension joints throughout UEs and LEs, 
        • no sensory deficits (per patient with light touch),
        • cerebellar function intact (finger-nose-finger), 
        • normal gait in ED,
        • no sensory deficit in GU region, 
        • able to squeeze buttock, 
        • normal rectal tone, 
      • as noted in HPI
    • MSK:
      • no recent trauma
      • no focal weakness, 
      • no pain in extremities or joints, 
      • as noted in HPI
    • Pysch:
      • normal speech, 
      • normal affect,
      • linear though process, 
      • no SI, 
      • no HI, 
      • appears able to care for self by evidence of being dressed, groomed, linear though processes expressed for history and plan after discharge, 
      • no AH, 
      • no VH, 
      • as noted in HPI
    • ID:
      • no recent antibiotics,
    • Endo:
      • no polyuria/polydipsia
      • as noted in HPI

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