REVIEW OF SYSTEMS
GENERAL/CONSTITUTIONAL: The patient denies fever, fatigue, weakness, weight gain or
weight loss.
HEAD, EYES, EARS, NOSE AND THROAT: Eyes – The patient denies pain, redness, loss
of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something
is in the eye and denies wearing glasses. Ears, nose, mouth and throat. The patient denies
ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis,
post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry
mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant
feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid
in the mouth or throat, food sticking in throat when swallows or painful swallowing.
CARDIOVASCULAR: The patient denies chest pain, irregular heartbeats, sudden changes in
heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet,
heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at
night or varicose veins.
RESPIRATORY: The patient denies chronic dry cough, coughing up blood, coughing up
mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.
GASTROINTESTINAL: The patient denies decreased appetite, nausea, vomiting, vomiting
blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain
relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry
stools or hemorrhoids.
GENITOURINARY: The patient denies difficult urination, pain or burning with urination,
blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to
urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones,
rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted
diseases.
MUSCULOSKELETAL: The patient denies arm, buttock, thigh or calf cramps. No joint or
muscle pain. No muscle weakness or tenderness. No joint swelling, neck pain, back pain or
major orthopedic injuries.
SKIN AND BREASTS: The patient denies easy bruising, skin redness, skin rash, hives,
sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands
or feet with cold, breast lump, breast pain or nipple discharge.
NEUROLOGIC: The patient denies headache, dizziness, fainting, muscle spasm, loss of
consciousness, sensitivity or pain in the hands and feet or memory loss.
PSYCHIATRIC: The patient denies depression with thoughts of suicide, voices in ?? head
telling ?? to do things and has not been seen for psychiatric counseling or treatment.
ENDOCRINE: The patient denies intolerance to hot or cold temperature, flushing, fingernail
changes, increased thirst, increased salt intake or decreased sexual desire.
HEMATOLOGIC/LYMPHATIC: The patient denies anemia, bleeding tendency or clotting
tendency.
ALLERGIC/IMMUNOLOGIC: The patient denies rhinitis, asthma, skin sensitivity, latex
allergies or sensitivity.
PHYSICAL EXAMINATION - Normal
Vital signs:
BP 120/80; P 68/min reg; RR 14/min; T 36.9 °C; Wt. 78 kg; Ht 175 cm;
General:
Well-developed, well-nourished, appearing stated age.
Alert, oriented to time, place, person, and situation. Recent and remote memory intact. Good
insight and cognitive function. No aphasia, dysarthria or hoarseness.
Gait and station normal, Rhomberg negative.
Skin warm, dry, with good turgor, No abnormal pigmentation, bleeding, rash, or other lesions.
Hair normal texture and distribution. No nail changes.
Head:
Normocephalic without scalp lesions.
Sensation intact over face. No facial asymmetry, muscles of facial expression intact.
Ears and nose without deformity, external tenderness or discharge
Hearing intact bilaterally by rough testing (or: to whisper)
Eyes: Conjunctivae pink, sclerae white, without jaundice. No en- or exophthalmos or ptosis of
lids. External ocular movements (EOM's) intact (or: full), no strabismus or nystagmus. Pupils
equal round, react to light and accommodation (PERRLA). Visual fields intact to
confrontation.
Mouth and Throat: Lips normal color, without lesions. Teeth present, good dental hygiene.
Gums (or: gingiva) and mucous membranes pink without bleeding, lesions or inflammation.
Tongue normal size and papillation, midline protrusion. Tonsils not enlarged (or: absent).
Palate elevates symmetrically, gag intact.
Neck:
Neck supple with full range of motion (ROM). No masses or tenderness. Jugular venous
distension (JVD) normal. Trachea midline. Thyroid not palpable (or: normal size and
consistency). Carotic pulses full and equal, without bruits.
Lymph Nodes: Occipital, pre- and postauricular, submandibular, anterior or posterior cervical,
or supraclavicular nodes not enlarged.
Chest & back:
No abnormal curvature of spine. Full range of motion, no muscle spasm or tenderness.
Breasts (female) symmetrical, normal size; no dimpling, masses, tenderness, or skin
changes. No nipple deformity or discharge.
Axillary lymph nodes nor enlarged.
Lungs:
Respiratory excursions full and symmetrical. Lungs resonant to percussion & vesicular
breath sounds throughout peripheral lung fields (an accepted abbreviation for normal lung
percussion and auscultation: “Clear to A&P”). No rales, ronchi, wheezes, or rubs. Vocal and
tactile fremitus normal.
Cardiovascular:
Point of maximal impact (or: impulse) (PMI) 5th intercostal space in mid-clavicular line (MCL),
not visible. No abnormal heaves or lifts. No thrill. Regular rate and rhythm. (RRR) 1 st and 2nd
sounds normal intensity (2nd sound physiologically split). No extra sounds or murmurs.
Abdomen:
Scaphoid without scars. No abnormal tympany. Normal bowel sounds, no bruits. Superfiecial
& deep palpation without organomegaly or masses; no direct or rebound tenderness, rigidity,
or guarding. Liver edge soft (or: not palpable), liver span 10 cm. Spleen normal size (or: not
palpable), kidneys not palpable.
Extremities:
No asymmetry or muscle atrophy. Full range of motion (ROM) of all joints.
Normal skin temperature. No edema, or superficial varicosities.
Inguinal lymph nodes not enlarged.
All distal pulses (or: femoral, popliteal, PT, and DP pulses) intact, full, and equal; no bruits
over femoral artery.
Rectal:
No external lesions. Good sphincter tone. No tenderness or masses. Prostate approx. 20
gms., firm, without tenderness or nodules. Brown stool.
Genitalia (male):
Penis without lesions. No urethral discharge. Testes normal size without masses or
tenderness. No scrotal masses. No hernia.
