2-3
Review of Systems:
This is an inventory of body systems obtained through a series of questions seeking to identify any signs/
symptoms the patient may be experiencing. There are 14 elements to the ROS.
CONSTITUTIONAL: Weight changes, fever, fatigue, weakness, etc.
EYES: Pain, redness, blurring, photophobia, decreased visual acuity, diplopia, etc.
ENT: Decreased hearing, pain, vertigo, tinnitus, epistaxis, sore throat, etc.
CARDIOVASCULAR: Palpitations, fainting, tachycardia, orthopnea, EKG results, etc.
RESPIRATORY: Wheezing, cough, sputum (color and quantity), dyspnea, pleuritic pain, etc.
GASTROINTESTINAL: Nausea, vomiting, diarrhea, bloody stools, constipation, abdominal pain,
anorexia, etc.
GENITOURINARY: Frequency, painful urination, hematuria, testicular pain, incontinence, penile
discharge, last menstrual period, etc.
MUSCULOSKELETAL: Joint pain or stiffness, muscle pain, decreased range of motion, swelling, etc.
SKIN/BREAST: Dryness, rashes, itching, jaundice, lumps, sores, changes in hair or skin, nipple
discharge, etc.
NEUROLOGICAL: Seizures, focal weakness, slurred speech, tremors, difficulty walking, paralysis,
numbness, headaches, etc.
PSYCHIATRIC: Nervousness, depression, mood changes, insomnia, etc.
ENDOCRINE: Diabetes, excessive thirst, cold intolerance, sweating, etc.
HEMATOLOGIC/LYMPHATIC: Anemia, easy bruising or bleeding, adenopathy, past transfusions, etc.
ALLERGIC/IMMUNOLOGIC: Allergies, prior immunizations, HIV test results, etc.
Past, Family, and Social History:
PAST MEDICAL HISTORY: This includes the patient’s significant prior medical problems, past
surgeries, current medications, medication allergies, and immunization history.
FAMILY HISTORY: This consists of a review of medical events in the patient’s
family that may be hereditary, or place patient at increased risk (e.g., colon cancer,
father had heart attack at age 40, etc.).
SOCIAL HISTORY: This is an age-appropriate review of past and current activities that
may affect the illness/injury. It includes employment, marital status, alcohol, drug
and tobacco use, living arrangements, etc.
Physical Examination:
Constitutional:
VITAL SIGNS: Height, weight, blood pressure, pulse rate, respiratory rate, and temperature.
GENERAL APPEARANCE: Development, nutrition, growth, body habitus, attention
to grooming, etc.
Ear, Nose, Mouth, and Throat:
EAR: Overall appearance of auricles, auditory canal (swelling, drainage, etc.), tympanic
membrane (erythema, blood, mobility, etc.), and assessment of hearing acuity.
NOSE: Examination of external nose, nasal mucosa, sinuses, septum, and turbinates for swelling,
redness, polyps, blood, rhinorrhea, deviation, perforation, etc.
MOUTH: Examination of lips, teeth, tongue, gums, etc. for dental caries, gingivitis, periodontal disease,
tooth loss, cyanosis, etc.
THROAT: Examination of oropharynx for lesions, symmetry, erythema, tonsillitis, etc.
Respiratory:
Examination should include inspection of chest (shape, symmetry, expansion, use of accessory muscles,
and intercostal retractions), percussion of chest (dullness, hyperresonance), palpation of chest (tenderness,
masses, tactile fremitus), and auscultation of lungs (equality of breath sounds, rubs, rales, rhonchi, and
wheezes).
Cardiovascular:
Examination should include palpation of heart (location, forcefulness of the point of maximal impact, thrills,
etc.), auscultation of heart (murmurs, abnormal sounds), assessment of pulse amplitude and presence of
bruits in various arteries (carotid, femoral, popliteal, etc.), assessment of jugular veins (distention, A, V, or