Medical Transcription Phrases & Words Occuring in Review of Systems - For Medical Transcriptionists:
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Appetite good. No weight change.
HEENT: Eyes: Cataracts removed. Mild glaucoma. He wears bifocals. ENT: No tinnitus or hearing loss.
CARDIOVASCULAR: As above.
RESPIRATORY: No cough or sputum.
GASTROINTESTINAL: No abdominal pain. No constipation or diarrhea. No melena or bloody stools.
GENITOURINARY: No hematuria or dysuria. Nocturia 2 or 3 times at night.
EXTREMITIES: Musculoskeletal: History of gout flaring up with warfarin.
SKIN: No pigmentation change, dermatitis or hair loss notable.
NEUROLOGICAL: He has peripheral neuropathy. He has some mild atrophy in his fingers. No headache, paralysis or convulsions.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, chills.
HEENT: No visual disturbance, no photophobia. No otalgia, no difficulty swallowing or speaking.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: Epigastric pain.
GENITOURINARY: No difficulty urinating. No urinary retention or urinary incontinence.
MUSCULOSKELETAL: No joint pain or swelling.
NEUROLOGIC: No paresthesias, anesthesias.
SKIN: No rashes.
PSYCHIATRIC: No hallucinations or delusions.
Review of systems otherwise negative.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fevers, weight change, headaches, visual changes, nausea or vomiting.
EYES: Denies cataract, glaucoma.
ENT: Denies nose bleeds, gum disease.
INTEGUMENTARY: Denies healing problems or rashes.
VASCULAR: Denies peripheral vascular disease, deep vein thrombosis, and varicose veins.
CARDIOVASCULAR: Has hypertension. Denies arrhythmia, myocardial infarction, congestive heart failure.
RESPIRATORY: Occasionally has wheezing, but denies the diagnosis of emphysema, bronchitis.
GASTROINTESTINAL: Denies peptic ulcer disease, liver disease, hepatitis.
MUSCULOSKELETAL: Denies gout or arthritis.
UROGENITAL: Denies any kidney disease, kidney failure.
ENDOCRINE: Denies diabetes or thyroid disease.
HEMATOLOGIC: Denies bleeding disorder, anemia.
IMMUNOLOGIC: Denies history of cancer, immunosuppression.
NEUROLOGIC: Denies stroke, TIAs or seizures.
PSYCHIATRIC: Denies depression or anxiety.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Nausea and vomiting as above.
SKIN: No rashes.
HEENT: No hearing aid.
RESPIRATORY: No asthma, TB, cough or shortness of breath.
CARDIOVASCULAR: No MI or angina.
GASTROINTESTINAL: No ulcers.
GENITOURINARY: No stones or infections.
NEUROLOGIC: History of stroke.
PSYCHIATRIC: No depression.
MUSCULOSKELETAL: Positive gout.
ENDOCRINE: Positive diabetes.
HEMATOLOGIC: No anemia. On Plavix.
ALLERGIES: As above.
REVIEW OF SYSTEMS:
The patient denies any fever or weight loss. Denies any blurry vision or diplopia. Denies any cough, rhinorrhea or sinusitis. The patient denies any chest pain, palpitations, dyspnea on exertion. Denies any shortness of breath, cough or wheeze. The patient denies any nausea or vomiting. Denies any hemetemesis. Denies any hematochezia. Denies any melena. Denies any urgency, frequency or dysuria. Notes vaginal bleeding as per the HPI. Notes no easy bruising or bleeding. The patient notes no rash or lesion. The patient notes no lightheadedness, loss of consciousness, loss of coordination, weakness or paresthesias.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fever or weight loss.
HEENT: Denies visual changes, congestion, sore throat, sinus pain.
CARDIOVASCULAR: Reports chest pain associated with cough. Denies palpitations. Reports dyspnea on exertion and paroxysmal nocturnal dyspnea last night. Denies any edema or syncope.
RESPIRATORY: Reports shortness of breath and cough. Denies congestion, mild wheezing, no sputum production.
GASTROINTESTINAL: Denies any abdominal pain, hematemesis, melena, nausea, vomiting or reflux.
GENITOURINARY: She denies any dysuria or urgency.
MUSCULOSKELETAL: Denies any muscle or joint pain.
SKIN: Denies any rash or pruritus.
NEUROLOGIC: Denies any headaches, vertigo, weakness, numbness or tingling.
ENDOCRINE: Denies any polyuria or polydipsia.
HEMATOLOGIC: Denies any abnormal bleeding, bruising or lymphadenopathy.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fever, chills.
HEENT: No bleeding, congestion, pain, discharge, epistaxis or rhinorrhea.
RESPIRATORY: No shortness of breath, cough, hemoptysis.
CARDIOVASCULAR: No chest pressure, tightness, heaviness, palpitations, syncope.
GASTROINTESTINAL: No nausea, vomiting, pain, melena, hematochezia, hematemesis, constipation, diarrhea.
GENITOURINARY: No dysuria, hematuria, change in color or smell or flank pain.
IMMUNOLOGICAL: No hives, itching, history of immune deficiency.
LYMPHATIC: No history of adenopathy, splenomegaly, splenectomy.
HEMATOLOGIC: No history of coagulopathy, thromboembolic disease, anticoagulant therapy.
NEUROLOGIC: Pain radiates down the right leg. Denies numbness, tingling. Denies ataxia. Denies trouble swallowing, slurred speech, blurry vision, diplopia, vertigo.
INTEGUMENTARY: Denies sweats, wounds, rash, bites, stings or IV drug abuse.
ENDOCRINOLOGICAL: No polyuria, polyphagia, polydipsia or temperature intolerance.
MUSCULOSKELETAL: As above. All other systems negative.
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