Appendix B. REVIEW OF SYSTEMS (EXHAUSTIVE) Development of a HPI: ____ Chief complaint (description of current episode) ____Duration of current episode ____Onset (gradual vs. sudden ____Progression since onset (lessening vs. worsening) ____Precipitating factors ____Exertion ____Trauma/muscle strain ____Emotional stress ____Food intake ____Aggravating/relieving factors ____Activity/exercise ____Position ____Breathing/coughing/sneezing ____Movement ____Touch (tenderness) ____Food intake ____Self Rx ____Physician/other Rx ____Associated symptoms ____Prior similar episodes ____Number of prior episodes ____Frequency of episodes (increasing/decreasing?) ____Severity of episodes changing? ____Durations of episodes changing? ____Precipitating factor(s) ____Exertion ____Emotional stress ____Food Intake ____Exacerbating/relieving factors ____Activity/exertion ____Position ____Breathing/coughing/sneezing ____Movement ____Touch (tenderness) ____Food intake ____Self Rx ____Physician/other Rx ____Associated symptoms ____Prior diagnosis and/or work-up (who, where, when?) ____Hx related illness and/or surgery [A review of appropriate systems should be conducted at this point.] ____Impact of illness on daily routine/lifestyle/employment ____Patient concerns about illness ____FH similar illness ____Chronic diseases/disabilities ____Current medications ____Medication allergies

Occupational/Activity History ____Occupation ____Hobbies/recreational activities ____Household chores/duties Exposures: ____Asbestos ____Dust (silicates, coal, plaster, insulation) ____Solvents/chemicals (inc. vapors) ____Noise ____Heavy metals (e.g. lead: paint, plumbing; arsenic: treated lumber) ____Toxins/caustics (e.g. pesticides, herbicides, Rodenticides) ____Medications (e.g. in anesthesia and chemotherapy nurses) Physical activities: ____Sports/hobby-related ____Occupational

Pain Review – An example of HPI Development: ____Pain: Location (precise) ____Pain: Episodic vs. chronic ____Pain: Duration of current episode ____Pain: Quality (aching, dull, sharp) ____Pain: Intensity/severity (mild/moderate/severe) ____Pain: Deep vs. superficial ____Pain: Radiations ____Pain: Onset ____Pain: Progression (stable vs. increasing intensity) ____Pain: Precipitating factor(s)? ____Trauma/muscle strain ____Exercise/exertion/activity associations ____Emotional stress ____Food intake ____Pain: Aggravating/relieving factors ____Position ____Movement ____Touch (overlying tenderness) ____Breathing/coughing/sneezing ____Food intake ____Self Rx (medications, etc.) ____Physician Rx ____Pain: Interference with sleep ____Pain: Associated Sx ____Preceding illness/chronic diseases ____Prior similar pain ____First time pain noted ____Number of prior episodes ____Durations of prior episodes ____Prior pain like/unlike present episode (how different?) ____Episodes increasing/decreasing in frequency? ____Precipitating factors for prior episodes ____Exertion/activity associations ____Food intake ____Emotional Stress ____Aggravating/relieving factors ____Position ____Movement ____Touch (overlying tenderness) ____Breathing/coughing/sneezing ____Food intake ____Self Rx (medications, etc.) ____Physician Rx ____Related to prior illness(es) or surgeries ____Psychosocial stressors [Appropriate ROS data should be included at this point: e.g. for chest pain-CV, pulm, GI, MS and psych ROS data may all be relevant here.] ____Impact of pain on lifestyle/daily routine ____Patient concerns about pain ____FH similar problems/pain ____Current meds ____Chronic diseases ____Medication allergies

Infectious Disease Review: ____Contact with ill individuals (children, spouse, friends, occupational) ____Recent travel (esp. foreign) ____Outdoor activities ____Insect exposure (ticks, spiders, mosquitoes) ____Unpurified water consumption (giardiasis) ____Animal exposures ____Pets (inc. ill pets) ____Farm animals ____Endemic animals (birds, rats, mice, skunks, squirrels, bats, other wild) ____Carcasses (e.g. from hunting, taxidermy) ____TB contact ____Last TB skin test ____Last CXR ____Immunizations (inc. flu, pneumovax, hepatitis B, rubella, tetanus) ____Recent and/or recurrent infection Hx ____Immunological deficiency Hx (heritable, 2 CA/HIV) ____Medications (esp. steroids, immuno- suppressive, CA meds, antimicrobials) ____Rash/skin changes ____Lymphadenopathy ____Weight loss ____Night sweats/fever/chills/rigors ____Respiratory Sx ____Sore throat ____Runny nose ____Ear congestion ____Cough ____Sputum +/- and color esp. yellow/green) ____Hemoptysis ____Dyspnea (resting, exertional) ____Chest pain (esp. pleuritic) ____CNS Symptoms ____Headache ____Stiff neck ____Impaired mentation/consciousness ____Seizure ____Heart Problems ____Rheumatic/valvular heart disease (murmur) Hx ____Changes in Urination ____Dysuria ____Frequency/nocturia ____Urgency ____Void volume changes ____Back/flank pain ____Hx recurrent UTI’s and/or UT abnormalities/surgeries ____Reproductive tract problems ____Discharge ____Lesions ____Hx VD/RT infections ____Number and sex of present & past sex partners ____Partners with HIV/AIDS or HIV risk factors ____Dyspareunia (women) ____Abdominal pain/tenderness ____LMP ____Tampon use +/- ____Contraception (esp. IUD)

General ____Age ____Height/weight ____Occupation ____General health ____Febrile ____Night sweats ____Appetite ____General mood ____Chronic diseases ____Disabilities/impairments ____Medications (OTC and prescription) ____Medication allergies ____Weight changes (esp. recent) ____Prior health care

Skin/Hair/Nails ____Urticaria ____Rashes ____Lesions (eruptions, abscesses, ulcers) ____Dry Skin ____Pruritus ____Skin color changes ____Pallor ____Cyanosis ____Hyperpigmentation ____Hx of biopsy ____Hx dermatological disease ____Eczema ____Psoriasis ____Acne ____Nail color changes ____Brittle nails ____Nail hemorrhages ____Clubbing ____Change in hair distribution ____Alopecia ____Hirsutism ____Brittle/dry hair ____Hair texture (esp. changes)

Cardiovascular: ____Chest pain (esp. exertional, see pain section below) ____Dyspnea ____Resting ____Exertional ____Orthopnea ____PND ____Nocturia/urinary frequency ____Edema (esp. leg/foot) ____Palpitations/irregular heartbeat ____Tachycardia/bradycardia ____Fainting/dizziness/syncope ____Postural hypotension ____Claudication ____Varicosities ____Raynaud Sx ____Hx CV diseases ____MI/angina ____HTN ____CHF ____Rheumatic/valvular disease (murmurs) ____Arrhythmias ____Hx pulmonary emboli/DVT’s ____Hypercholesterolemia ____Postmenopausal +/- ____Hx diabetes ____Hx smoking

HEET/Neck: ____Head/Neck problems ____Lumps/bumps/lymphadenopathy ____Headaches ____location ____duration ____how relieved ____Stiff neck ____Neck pain ____Sinus problems ____Jaw discomfort (TMJ) ____Thyroid problems ____Syncope ____Vertigo ____Injury ____Eye problems ____Diplopia ____Blurring ____Blindness/vision loss ____Color blindness ____Cataracts +/- ____Glaucoma +/- ____Last glaucoma test ____Impaired visual fields/peripheral vision ____Flashing light/stars ____Floaters ____Eye Fatigue ____Pain ____Photophobia ____Conjunctivitis ____Inflammation ____Dysfunctional tearing ____Pruritus ____Blepharospasm ____Nystagmus ____Corrective lenses +/- (inc. contacts) ____myopia ____hyperopia ____Scotomata ____Last eye exam ____Ear problems ____Hearing impairment ____Noise exposures ____Balance/equilibrium problems ____Tinnitus ____Congestion ____Pain ____Drainage ____Infection ____Mastoiditis ____Nose problems ____Olfaction/Anosmia ____Obstruction ____Sinusitis ____Congestion ____Rhinorrhea ____Epistaxis ____Deviated septum ____Seasonal problems ____Mouth and Throat Problems ____Teeth problems ____Malocclusion ____Dentures +/- ____Toothaches ____Last dental exam ____Mouth/tongue lesions ____Gingivitis/bleeding gums ____Pain (inc. cold sores) ____Sore throat ____Tonsillitis (tonsils +/-) ____Post-nasal drip ____Voice changes/hoarseness/laryngitis

Respiratory: ____Dyspnea ____Resting ____Exertional ____Orthopnea ____PND ____Cough ____Productive +/- ____Sputum color ____Hemoptysis ____Yellow/green sputum ____Sputum quality ____Sputum (foul odor?) ____Chest pain (esp. pleuritic cyanosis/pallor) ____Cyanosis/pallor ____URI Sx (other) ____Sore throat ____Rhinorrhea/nasal congestion ____Ear congestion ____Hx pulmonary disease ____COPD ____Asthma ____Recurrent pulmonary infections/pneumonia ____Cystic fibrosis ____Hx TB/TB exposure ____Occupational pulmonary exposures ____Smoking Hx

Gastrointestinal: ____Appetite ____weight loss ____Mouth lesions ____Dysphagia ____Sour mouth taste ____Pyrosis ____Antacid use +/- ____Nausea/emesis ____Hematemesis ____Dysgusia ____Jaundice ____Dark urine ____Abdominal pain (esp. associated with eating, see pain section below) ____Flatulence ____Eructation ____Stool changes ____Color ____Red ____Black/tarry ____Grey/tan/pale ____Odor (esp. foul) ____Consistency (soft/loose/hard) ____Frequency (diarrhea/constipation) ____Stool incontinence ____Stool guaiac +/- (hen, results?) ____Proctoscopy/barium enema +/- ____Hx GI disease ____PUD ____Reflux esophagitis ____Diverticulosis/itis ____Inflammatory bowel disease ____Irritable bowel syndrome ____Colon polyps/CA ____Liver disease (esp. cirrhosis, hepatitis, biliary tract) ____Cholecystitis ____Pancreatitis ____Hemorrhoids ____Hx prior abdominal surgery ____Hx hernias ____Coffee intake ____Alcohol intake ____Aspirin NSAID intake ____Hx smoking

Nutritional/Diet Survey: ____Special diet +/- (e.g. ovo/lactam vegetarian, low sodium, low cholesterol; incl. rational, e.g. Kosher, Hx diabetes) ____Number of meals consumed daily (inc. times meals taken) ____Preparation of consumed meals (e.g. self at home, McDonalds, meals on wheels) ____Typical meals (inc. concrete examples) ____Between meal eating ____Beverages (inc. soft drinks, coffee, alcohol) ____Dietary supplements (inc. vitamins, health food preparations) ____Dieting? Urological: ____Urination problems ____Dysuria ____Hematuria/urine color change ____Pyuria ____Void-volume changes ____Frequency changes ____Dribbling ____Hesitancy ____Incontinence ____Enuresis ____Oliguria ____Hx Ut disease/anomalies ____UT infection (esp. recurrent) ____Renal failure ____Stones ____Prostate problems

Hematologic/Lymphatic: ____Bleeding problems (inc. hemophilia ____Hemoptysis ____Bruising ____Slow clotting (inc. hemophilia) ____Hematuria ____Heavy periods/abnormal vaginal bleeding ____Melena ____Hematochezia ____Anemia (inc. sickle cell, thalassemia) ____Prior blood transfusions (and rxns) ____Lymphadenopathy (inc. cervical, inguinal, axillary) ____Impaired wound healing ____Recurrent infections +/- ____Weight loss ____Hx immunosuppression ____HIV/AIDS ____Hx CA

Reproductive: ____Sexually active +/- ____Frequency of intercourse ____Number and sex(es) of partners ____VD/HIV/AIDS in partners? ____Sexual dysfunction ____Impotence ____Dyspareunia ____Vaginismus ____Decrease libido ____Abdominal pain (esp. during intercourse or menstruation, see pain section) ____Genital lesions ____Discharge ____Odor ____Bloody? ____Pruritus ____Menstrual Hx ____Age of menarche ____Age at menopause ____Post menopausal Sx +/- ____LMP ____Duration of bleeding ____Pattern/severity of bleeding ____Frequency and regularity of periods ____Spotting ____Premenstrual syndrome ____Tampons +/- ____Contraception ____Pregnant? ____Gravida x? ____Para x? ____Abortions x? ____Last PAP ____Testicular problems ____Pain ____Lumps/enlargement ____Injury ____Hernia ____Hx VD ____Chlamydia ____GC ____Syphilis ____HIV +/- AIDS ____Hx reproductive disorders? ____Inability to conceive ____PID ____Ectopic pregnancy ____RT surgery +/- (e.g. hysterectomy, vasectomy) ____Breast problems? ____Routine self exams +/- ____Lumps ____Pain/tenderness ____Discharge ____Retraction of nipple ____Dimpling of skin

Endocrine/Metabolic: ____Weight loss/gain ____Heat/cold/intolerance ____Weakness/fatigue ____Diaphoresis ____Hyperphagia ____Nervousness/irritability ____Palpitations/tachycardia ____Hypertension ____ Sleep changes ____Polyuria ____Nocturia ____Change in urinary frequency +/- ____Excessive thirst ____Vision changes ____Visual fields/peripheral vision ____Changes in skin pigmentation +/- ____Changes in bowel movements ____Changes in hair and hair distribution ____Galactorrhea ____Gynecomastia ____Menstrual changes ____LMP

Musculoskeletal: ____Bone/joint problems ____Pain (inc. backache) ____Inflammation/swelling ____Calor/warmth ____Erythema/redness ____Tenderness ____Limitation of movement ____Stiffness ____Daily fluctuation ____Crepitus ____Interference with daily activities ____Hx bone disease ____Fractures/deformations ____Dislocations ____Arthritis ____Osteoporosis ____Gout ____Muscle/other rheumatologic problems ____Myalgias ____Tenderness ____Weakness ____Atrophy

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____Duration of bleeding ____Pattern/severity of bleeding ____Frequency and regularity of ____Spotting ____Premenstrual syndrome ____Pregnant? ____Gravida x? ____Para x? ____Abortions x? ____Fertility known? ____Impotence ____Libido

____Fasciculations ____Cramping ____Raynaud s phenomenon ____Malar/other rash ____Hx muscle disease ____Muscular dystrophy ____Collagen vascular/rheumatologic

Neurological: ____Headaches ____Dizziness/vertigo ____Fainting/LOC ____Seizures ____Tremor/movement disorder ____Tic ____Memory impairment ____Impaired cognition ____Motor impairment (inc. gait) ____Paresis ____Paralysis ____Impaired speech/dysphasia, aphasia ____Sensory impairment (numbness/tingling) ____Paresthesia ____Hyperesthesia ____Hypesthesia ____Coordination impairment ____Ataxia ____Apraxia ____Vision problems +/- ____Visual fields ____Amaurosis fugax ____Hx neuro problems ____CVA/TIA ____Parkinson s ____Seizure disorder ____Dementia ____CP ____MS ____Trauma

Mental Status Examination: ____Orientation (person, place and time) ___Affect ____Speech/language ____Writing/figure reproduction ____Memory (short and long term) ____Calculation (e.g. serial sevens) ____Proverb interpretation ____Judgment [See also ROS psych section.]

Psychological/psychiatric: ____Depression ____Duration ____Elation (alternating w/depression) ____Weight change ____Appetite change ____Sleep change ____Loss of interest ____Libido changes ____Moodiness ____Hallucinations (inc. auditory, visual, gustatory, olfactory, tactile) ____Delusions (inc. persecutory) ____Anxiety/nervousness ____Agoraphobia ____Substance abuse (inc. drugs, alcohol, prescription meds) ____Anorexia nervosa-binge/purge ____Suicidal/homicidal ideation ____Psychosocial stressors ____Family life/romantic life ____Financial ____Employment ____Peers/social life ____Schools ____Hx being abused ____Hx psychiatric disorders ____Depression ____Bipolar ____Psychosis ____Substance abuse ____Anxiety ____Eating disorder (anorexia-binge/purge)