GeriROS Quick Review of Systems

Transcription

1 How are your bowels? Follow-Up s Are you constipated? 1. How often do you move your bowels? (Establish patient s baseline.) 2. When was your last bowel movement? 3. Are you passing gas? 4. Do you have to strain? 5. Are your stools hard? 6. Do you use laxatives? How often? When was the last time you used one? 7. Review medications to identify constipating agents (i.e., opioids). 8. Any associated symptoms? Nausea, vomiting? Abdominal pain, cramps? Do you have diarrhea? 1. For how long? 2. How many times a day? 3. Describe it (consistency, color, etc.). 4. Any blood in it? Fresh? Melena? ( Black, tarry? ) Clots? 5. Any change in dietary habits related to onset of diarrhea? 6. Any associated symptoms? Abdominal pain, cramps? Fever? Nausea, vomiting? Mucus? 1

2 How is your sleep? 1. Do you have difficulty falling asleep? 2. Do you have any difficulty staying asleep? 3. Are you excessively sleepy during the day? Follow-Up s 1. Do you often awaken during the night and at what time? (For examples, symptoms of asthma may occur early in the morning; depressed patients may wake up at 2 or 3 am.) 2. Are you able to fall back asleep after awakening? (Depressed patients usually can t.) 3. Do you wake up during the night with shortness of breath, chest tightness, or cough? (COPD, asthma) 4. Do you experience shortness of breath while lying flat? (CHF) 5. Do you wake up at night with shortness of breath, chest pain, or chest tightness? (CAD) 6. Do you snore or have breathing pauses during sleep? (OSA; ask bed partner if available.) 7. Are you excessively sleepy during the day? (OSA) 8. Do you wake up frequently during the night with heartburn? (GERD) 9. Do you have uncomfortable, crawling, aching sensations in the legs at rest? (restless leg syndrome) 10. Do you kick or have leg cramps? (RLS) 11. Are you depressed or stressed? 2

3 How is your urine? Do you loose urine involuntarily? Follow-Up s 1. Do you often feel the urgent need to urinate? 2. Are you unable to get to the toilet on time? Do you have any physical limitation (arthritis, pain, weakness, balance or gait disturbance, etc.)? 3. Do you lose urine when you cough, laugh or sneeze? 4. Do you often have wetting accidents? 5. How often do you void? 6. Do you have any burning or pain when you urinate? 7. Has the urine color or smell changed? 8. Have you seen blood in your urine? 9. Do you have frequent urinary tract infections? BPH: 10. Do you wake up at night to urinate? How often? 11. Is the stream weaker than it was? 12. Do you have problems initiating the stream? 13. Do you have dribbling? 14. Do you feel a sensation of incomplete voiding? 3

4 How is your appetite? Have you lost weight? Follow-Up s 1. Are you trying to lose weight? 2. Have you lost your appetite? 3. Any trouble with the taste of food? 4. Do you have any problems getting the food? 5. Do you have any problems cooking? 6. Can you feed yourself? 7. Do you have any problems chewing? Do you wear dentures? Do they fit well? Do your gums hurt when you chew? 8. Do you have problems swallowing? Do you choke or cough when eating? Is it worse with liquids, solids, or both? Do you feel the food gets stuck? Does it hurt when you swallow? 9. If the patient is not sure about weight loss: Do your clothes fit? Have you moved your belt up a notch? Have people told you that you look thinner? 4

5 How is your memory? Are you or a family member concerned about your memory? (You may have to ask these questions to your patient s caregiver.) Follow-Up s 1. Are you retired? Yes: Why did you retire? No: Are you experiencing memory loss that affects your job or lifestyle? 2. Are you having trouble remembering: To take your medications? Appointments? Recent events? The names of familiar people or things? 3. Do you get lost in familiar places? 4. Are you having difficulty performing familiar tasks, such as cooking, driving, or paying bills on time? 5. Do you often forget the date? 6. Are you constantly misplacing things? 7. Are you still driving? Yes: Are you having trouble driving? No: Why did you quit? 8. Have you noticed any changes in mood or behavior? 9. Have you noticed a change in personality? 10. Have you noticed loss of initiative? 5

6 Are you having any pain? Are you having any pain? Follow-Up s 1. Intensity Use scale of 0 to 10: 0 = no pain, 10 = worst pain imaginable If unable to use scale, describe: mild, moderate or severe 2. Location Where is the pain located? 3. Onset When did the pain start? What were the circumstances? 4. Duration How long does it last? 5. Radiation Does the pain stay in one place, or does it radiate? Where does it radiate to? 6. Quality Can you describe the pain? Is it sharp, dull, pressure, burning, stabbing? 7. Associated symptoms Is the pain interfering with your sleep? Is the pain interfering with your daily activities? Have you noticed a decrease in appetite? Are you having difficulty controlling your bowels or bladder? Do you have difficulty getting to the restroom because of the pain? 8. Aggravating and palliating factors What makes the pain worse? What makes the pain better? 6

7 Have you fallen? Follow-Up s Have you fallen? 1. Have you fallen in the last year? How many times? 2. Did you suffer any injuries? Did you go to your doctor? 3. Where did you fall? 4. Do you get dizzy when you stand up? 5. Do you experience joint pains when you walk? 6. How far can you walk? Do you get short of breath? Do you get chest pain? Do your legs hurt or cramp? 7. Do you use a cane or walker? 8. How is your vision? Your hearing? 7