Basics of Medical Transcription

Review of Systems (Common Terms)

CONSTITUTIONAL:

Fever

Chills

Fatigue

Recent weight loss

Headache

Seizures

Syncope

Decreased or blurred vision

Tinnitus

Decreased hearing

Runny or stuffy nose

Epistaxis

Sore throat

Difficulty swallowing

Chest pain

Chest pressure

Shortness of breath

Cough

Hemoptysis

Abdominal pain

Nausea

Vomiting

Diarrhea

Black or bloody stools

Bloody or coffee ground-like emesis

Focal numbness, weakness or paresthesias

Rashes

Easy bleeding or bruising.

Negative for weakness, weight loss, appetite loss, chills, fever, or sweats.

SKIN:

Negative for rash, itching, or changes in the skin coloration or texture.

HEENT:

Negative for head injury, headache, syncope, seizures, dizziness, paralysis, strokes, or memory loss.

Head: No headaches, dizziness or syncope.

Eyes:

Diplopia, discharge, blurred vision, cataracts, or glaucoma

NOSE AND SINUSES: No congestion, drainage or bleeding.

THROAT: No sore throat, tenderness, no trouble swallowing.

NECK: No stiffness or pain with movement.

PULMONARY: No cough, sputum production, shortness of breath, wheezing or coughing blood.

CARDIOVASCULAR: No chest pain, tightness or heaviness in chest. No palpitations, dyspnea on exertion, PND, orthopnea, claudication.

GASTROINTESTINAL: No pain, cramps, nausea, vomiting, abdominal bloating, diarrhea, or constipation. No black or red stools.

GENITOURINARY: No increase or decrease in frequency of voiding. No nocturia, dysuria, hematuria, incontinence or kidney stones or erectile dysfunction.

MUSCULOSKELETAL: No pain, stiffness, redness or swelling of the joints.

NEUROLOGICAL: No numbness, tingling or weakness. No tremors of the extremities.

PSYCHOLOGICAL: No depression, anxiety, hallucinations, change in behavior.