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.