*Reference* Review ofSystems/ Medical
Review Of Systems: --Constitutional: C/O Fatigue Fever Chills Malaise Generalized Weakness Diffuse Pain Sleeping Problems Night Sweats Weight Changes . Denies: --Head: C/O Headaches Dizziness Syncope Sinus Pain Loc . Denies --Eyes: C/O Vision Loss Blurriness Blind Spots Floaters Diplopia Photophobia Eye Pain Halos Erythemia Drainage Change In Appearance Dryness --Ears: C/O Ear Pain Tinnitus Hearing Loss Fullness In Ears Vertigo Frequent Infections --Nose: C/O Loss Of Smell Obstruction Epistaxis Congestion Tenderness Lesions --Mouth & Throat: C/O Hoarseness Change In Voice B Sore Throat Bleeding In Mouth Hemoptysis Swollen Gums Recent Abscess Recent Extractions Soreness In Mouth Soreness In Tongue Ulcers Change In Taste Change In Voice --Neck: C/O Neck Pain Stiffness Edema --Cardiac: C/O Chest Pain Dyspnea Orthopnea Palpitations Shortness Of Breath W/ Activities Loss Of Consciousness Paroxysmal Nocturnal Dyspnea Need To Elevate Head At Night Due To Sob --Vascular: C/O Claudication Color Changes In Extremities Parathesias Coldness In Extremities Tendency To Bruise --Respiratory: C/O Pain W/ Respiration Cyanosis Coughing Wheezing Sputum Shortness Of Breath Exercise Intolerance W/ Activity --Gastrointestinal: C/O Appetite Changes Heartburn Dysphagia Abdominal Pain Nausea Vomiting Diarrhea Change In Stools Flatulence Anorexia Hematemesis Intolerance To Foods Painful Bowel Movements Bloating Cramping Bright Red Blood Per Rectum Foul Smelling Dark Black Tarry Stools Tenesmus --Endocrine: C/O Thyroid Tenderness Thyroid Enlargement Excessive Thirst Excessive Hunger/Excessive Urination Heat Intolerance Cold Intolerance Unexplained Weight Changes Changes In Face Or Body Hair Striae Increased Hat Or Glove Size Mood Swings Sweaty Oligomenorrhoea Tremor, Palpitations Visual Disturbances Feeling Slow Feeling Tired Depression Thin Hair Croaky Voice Heavy Periods Dry Skin Orthostatic Symptoms, Darkening Of Skin In Non-Sun Exposed Places --Hematological/Lymphatic: C/O Anemia Purpura Petechia Prolonged Or Excessive Bleeding After Dental Extraction/Injury Bruising Blood Clots Enlarged Lymph Nodes Tender Lymph Nodes --Genitourinary: C/O Dysuria Urinary Frequency Urinary Urgency Hematuria Flank Pain Suprapubic Pain Nocturia Polyuria Dark Or Discolored Urine Hesitancy Terminal Dribbling Loss Of Force Of Stream Loss Or Urine W/ Laughing, Coughing, Sneezing, Exercise, Position Changes Loss Of Sensation Loss Of Control Reproductive (Female): C/O Change In Cycle Duration & Frequency Vaginal Bleeding Irregularities Vaginal Discharge Vaginal Pain Menstrual Pain Changes In Sexual Arousal Or Libido Infertility Painful Intercourse . Gravida Para Abortus . Lmp: Reproductive (Male): C/O Difficulty W/ Erection Difficulty W/ Sexual Arousal Lack Of Stamina Difficulty W/ Emissions Testicular Pain --Musculoskeletal: C/O Joint Pain Or Tenderness Joint Swelling Muscles Pain Rom Changes Bony Deformity Misalignment --Neurological: C/O Change In Sight Changes In Smell Change In Hearing Changes In Taste Change In Sensation Faints Fits Funny Turns Headache Paraesthesias Numbness Paralysis Limb Weakness Poor Balance Loss Of Coordination Speech Problems Seizures Tremors Memory Loss --Psych: C/O Depression Change In Sleep Patterns Anxiety Difficulty Concentrating Difficulty Paying Attention Change In Body Image Changes In Work & School Performance Paranoia Anhedonia Lack Of Energy Episodes Of Mania Episodic Change In Personality Sexual Or Financial Binges Irritability Tension Suicidal Thoughts Homicidal Thoughts --Breasts: C/O Breast Pain/Soreness Discharge Lumps Constitutional/General: Confirms: Fatigue Fever Chills Malaise Generalized Weakness Diffuse Pain Sleeping Problems Night Sweats Weight Changes Denies: Head: Headaches Dizziness Syncope Sinus Pain Loc Eyes: Vision Loss Blurriness Blind Spots Floaters Diplopia Photophobia Eye Pain Halos Erythemia Drainage Change In Appearance Dryness Ears: Ear Pain Tinnitus Hearing Loss Fullness In Ears Vertigo Frequent Infections Nose,Mouth, & Throat: Loss Of Smell Obstruction Epistaxis Congestion Tenderness Lesions Hoarseness Change In Voice B Sore Throat Bleeding In Mouth Hemoptysis Swollen Gums Recent Abscess Recent Extractions Soreness In Mouth Soreness In Tongue Ulcers Change In Taste Change In Voice Skin: Diagnosed Skin Conditions New Lesions Rashes Discoloration Hair Changes Neck: Neck Pain Stiffness Edema Cardiac: Chest Pain Dyspnea Orthopnea Palpitations Shortness Of Breath W/ Activities Loss Of Consciousness Paroxysmal Nocturnal Dyspnea Need To Elevate Head At Night Due To Sob Claudication Color Changes In Extremities Parathesias Coldness In Extremities Tendency To Bruise Respiratory: Pain W/ Respiration Cyanosis Coughing Wheezing Sputum Shortness Of Breath Exercise Intolerance W/ Activity Gastrointestinal: Appetite Changes Dysphagia Abdominal Pain Vomiting Diarrhea Change In Stools Flatulence Anorexia Hematemesis Intolerance To Foods Painful Bowel Movements Bloating Cramping Bright Red Blood Per Rectum Foul Smelling Dark Black Tarry Stools Tenesmus Endocrine: Thyroid Tenderness Thyroid Enlargement Excessive Thirst Excessive Hunger/Excessive Urination Heat Intolerance Cold Intolerance Unexplained Weight Changes Changes In Face Or Body Hair Striae Increased Hat Or Glove Size Sweaty Oligomenorrhoea Tremor, Palpitations Visual Disturbances Feeling Slow Feeling Tired Depression Thin Hair Croaky Voice Heavy Periods Dry Skin Orthostatic Symptoms, Darkening Of Skin In Non-Sun Exposed Places Hematological/Lymphatic: Anemia Purpura Petechia Prolonged Or Excessive Bleeding After Dental Extraction/Injury Bruising Blood Clots Enlarged Lymph Nodes Tender Lymph Nodes Genitourinary: Dysuria Urinary Frequency Urinary Urgency Hematuria Flank Pain Suprapubic Pain Nocturia Polyuria Dark Or Discolored Urine Hesitancy Terminal Dribbling Loss Of Force Of Stream Loss Or Urine W/ Laughing, Coughing, Sneezing, Exercise, Position Changes Loss Of Sensation Loss Of Control Reproductive (Female): Change In Cycle Duration & Frequency Vaginal Bleeding Irregularities Vaginal Discharge Vaginal Pain Menstrual Pain Changes In Sexual Arousal Or Libido Infertility Painful Intercourse Gravida (Been Pregnant): Para (Full Term): Premature Births: Abortus (Non Viable Pregnancies): Last Mestral Period: Pregnant: Reproductive (Male): Difficulty W/ Erection Difficulty W/ Sexual Arousal Lack Of Stamina Difficulty W/ Emissions Testicular Pain Hernias Musculoskeletal: Joint Pain Or Tenderness Joint Swelling Muscles Pain Rom Changes Bony Deformity Misalignment Integument: Pruritis Stria Wounds Pigmentation Changes Acanthosis Nigricans Nodules Lumps/Bumps Excessive Dryness Texture Changes Eruptions Neurological: Change In Sight Changes In Smell Change In Hearing Changes In Taste Change In Sensation Faints Fits Funny Turns Headache Paraesthesias Numbness Paralysis Limb Weakness Poor Balance Loss Of Coordination Speech Problems Seizures Tremors Memory Loss Change In Sleep Patterns Difficulty Concentrating Difficulty Paying Attention Change In Body Image Changes In Work & School Performance Paranoia Anhedonia Lack Of Energy Episodes Of Mania Episodic Change In Personality Sexual Or Financial Binges Tension Suicidal Thoughts Homicidal Thoughts Social: Change In Home Relationships Employment Substance Use Exercise Exposure Function: Change In Activities Of Daily Living Memory Capacity Breasts: Breast Pain/Soreness Discharge Lumps Adult Medical Hx Not Applicable Abortion Alcoholism Arthritis Asthma Brain Injury Cancer, Nos Chronic Pain Constipation Copd Crohn's Disease Dental Disorders Emphysema Epilepsy Fibromyalgia Hepatitis Hypertension Hiv Infection Irritable Bowel Syndrome Motor Neuron Disease Obesity Renal Disease Shingles Sleep Disorder Std Stroke/Cva Tuberculosis Thyroid Disorders Childhood Medical Hx Chicken Pox Ear Infections Ear Tubes Eating Disorder Encopresis Enuresis Measles Mononucleosis Mumps Polio Rheumatic Fever Rubella Scarlet Fever Smallpox Whooping Cough
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 1088 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote