REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. The patient denies headache, nausea, vomiting, or visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough and hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation, or diarrhea. Urinary:  The patient has normal urination. Musculoskeletal:  The patient denies muscle weakness, pain, or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  The patient denies recent URI, fever, chills, weight loss or night sweats. No headache, visual symptoms, stiff neck. Had no associated neck, arm, jaw pain or pressure today. Does have chronic back and body aches, which are diffuse and varying in site from day to day. Denies significant abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. No swelling of her hand, feet or face. No neurologic symptoms. No rash. No lymphadenopathy. A 14-point review of systems is otherwise negative.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  No fever. No chills. No dizziness. No weakness.

EYES:  No pain, erythema, or discharge. No blurring of vision.

ENT:  No sore throat, URI symptoms. No epistaxis. No tinnitus.

CARDIOVASCULAR:  No chest pain. No palpitations. No lower extremity edema.

RESPIRATORY:  No shortness of breath, cough, pain with respiration, pleuritic chest pain. No hemoptysis. No dyspnea. No paroxysmal nocturnal dyspnea.

GASTROINTESTINAL:  Normal appetite. No nausea, vomiting, diarrhea. No pain. No bloating. No melena.

GENITOURINARY:  No frequency, urgency, nocturia. No hematuria or dysuria.

MUSCULOSKELETAL:  No arthralgias or myalgias.

INTEGUMENTARY:  No swelling. No bruising. No contusions. No abrasions. No lymphangitis.

NEUROLOGIC:  No headache. No neck pain. No numbness or tingling of the extremities. No weakness.

PSYCHIATRIC:  No confusion.

ENDOCRINE:  No fatigue. No weakness. No history of thyroid, diabetes or adrenal problems.

HEMATOLOGICAL:  No bleeding. No petechiae. No bruising.

ALLERGIES:  No asthma. No urticaria.

REVIEW OF SYSTEMS:  The patient denies any neck, arm, jaw, back, chest pain or pressure symptoms that are new. No palpitations. No dizziness. No sweats. Denies significant headache, visual symptoms, stiff neck. No recent URI, fever, chills, weight loss or night sweats. No abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. Has had no shortness of breath. Denies any swelling of his hands or face or his right lower extremity. No trauma. No skin lesions. No lymphadenopathy. A 14-point review of systems otherwise negative.

REVIEW OF SYSTEMS:  Without fever, chills, weight loss, or night sweats. No URI symptoms, no headache, visual symptoms, stiff neck, no trouble walking, talking, weakness, numbness, tingling of extremities other than the above noted left arm symptoms today. Had no other recent chest pain, pressure. No swelling of his hands, feet, face or symptoms suggestive of CHF. No abdominal pain, change of bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms, testicular pain, ureteral discharge. No rash, no lymphadenopathy. A 14 point review of systems is otherwise negative.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient denies any fever or chills.  HEENT:  No headaches, sore throat.  Positive for left otalgia.  CARDIOVASCULAR:  No history of palpitation or arrhythmia.  RESPIRATORY:  History is negative for cough, productive sputum.  GASTROINTESTINAL:  History is negative for nausea or vomiting.  All other systems essentially negative.

REVIEW OF SYSTEMS:  The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin:  The patient denies itching, rashes, sores and bruises. Head:  The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck:  No complaints. Respiratory:  The patient denies shortness of breath, wheeze, cough or hemoptysis. Cardiac:  The patient denies chest pain or palpitation. Gastrointestinal:  The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary:  The patient has normal urination. The patient has amenorrhea for last 3 years. Musculoskeletal:  The patient denies muscle weakness. The patient denies pain or joint stiffness. The patient denies restriction of range of motion. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  No fevers, chills, lightheadedness, fainting, or weight loss. HEENT:  No visual problems, sore throat, or nasal congestion. CARDIOVASCULAR:  No chest pain, palpitations, or orthopnea. RESPIRATORY:  No cough, shortness of breath or hemoptysis. GASTROINTESTINAL:  See HPI. GENITOURINARY:  No flank pain, dysuria or hematuria. ENDOCRINE:  No polyuria or polydipsia. HEMATOLOGIC:  No bleeding disorder. SKIN:  No rashes or jaundice. All other systems reviewed and are negative.

REVIEW OF SYSTEMS: States she has a headache every day, very dull headache. Does not take anything for it. It only lasts for an hour or two and she is not sure what precipitates the headache. She feels that she does not know how much fluid she takes. Denies any caffeine use and she states these headaches are not new. She has had them for as long as she can remember. No lightheadedness or dizziness. No chest pain or shortness of breath. No cough, wheeze. No fever. No heartburn symptoms. No nausea or vomiting. She is happy with her weight. No constipation. No diarrhea. No genitourinary symptoms. No skin changes, rashes or lesions. Depression: She shrugs her shoulders and states she is not depressed and she denies anxiety. She says she sleeps well at night most of the time.

REVIEW OF SYSTEMS: The patient denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient denies itching rashes, sores and bruises. The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck: No complaints. Respiratory: The patient denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: The patient denies chest pain and palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: The patient complains of frequent urination. No blood in urine. No urine retention. No pain during urination. The patient usually goes to the bathroom during the night 2 to 3 times, during the daytime 3 to 4 times. Musculoskeletal: The patient denies muscle weakness. Denies pain, joint stiffness. The patient complains of low back pain radiating to the left lower extremity with numbness of the left lower extremities and episodes of weakness of the left lower extremities. The patient has restriction of range of motion at the lumbosacral spine on flexion and extension. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  Denies weight change, fatigue, weakness, fever, chills, night sweats. Skin: The patient complains of itching, rash on both lower extremities, located on anterior shins. No bruises and no ulceration. The patient denies headache, nausea, vomiting, visual changes. Eye, ears, nose, sinuses, mouth, throat and neck: No complaints. Respiratory: Denies shortness of breath, wheeze, cough, and hemoptysis. Cardiac: Denies chest pain or palpitation. Gastrointestinal: The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. Urinary: Has normal urination. Musculoskeletal: Denied muscle weakness. No pain or joint stiffness. The patient has full range of motion of the upper and lower extremities.

REVIEW OF SYSTEMS:  There is no history of fever, weight loss or cough. CNS:  No history of vision changes, seizure or weakness. ENT:  No history of congestion, postnasal drip, sore throat or hearing changes. Respiratory:  No history of shortness of breath, wheezing or chest pain. Cardiovascular: No history of chest palpitations or arrhythmias. GI:  No history of nausea, vomiting, diarrhea or abdominal pain. GU:  No history of dysuria, frequency or vaginal discharge. Musculoskeletal:  Positive for ankle pain, joint pain, joint edema as well as right lower extremity edema with some tenderness in the calf area.

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WORDS & PHRASES COMMONLY DICTATED UNDER THE FOLLOWING SECTIONS IN ROS:

CONSTITUTIONAL:

had some shaking

negative fever or chills

no fever, generalized weakness or malaise

no pyrexia or chills. No weakness or fatigue.

no significant weight changes

no unexplained weight loss

no weight loss, fever, chills, weakness or fatigue

the patient denies fever, weight loss, night sweats, fatigue or bleeding

the patient is rather clammy, pale-looking

arcus senilis

aural fullness

conjunctivae pink, no scleral icterus

contact lens worn

double vision

ears and nose externally normal

goiter

hard of hearing

Head is normocephalic and atraumatic. Eyes, ears, nose and throat are unremarkable

moist buccal mucosa

mouth has no sores

nasal discharge

negative for false teeth

negative for glaucoma or cataracts

negative for masses, hoarseness or snoring

no bleeding gingivae

no change in hearing

no diplopia or blurred vision

no dysgeusia

no dysphagia, dysphonia.

no earache, sore throat or runny nose

no epistaxis or rhinorrhea.

no eye pain

no glossodynia

no hearing loss

no lid lag, no exophthalmos, no xanthelasma

no mucosal lesions

no mucosal pallor

no otalgia, otorrhea

no photophobia

no postnasal drip

no scleral icterus

no scotomata

no sneezing or congestion

No tenderness or difficulty in swallowing

no thrush

no tinnitus or vertigo

no vision disturbances

no visual loss

no xerostomia

patient has full denture plates

PERRL, EOMI

pharynx normal

sinus congestion

The patient wears corrective glasses for reading

ulcerations in mouth secondary to chemotherapy

visual field deficit

wears dentures

clear to auscultation bilaterally

denies any tuberculosis, pneumonia, asthma, pleurisy, bronchitis or sinusitis

dyspnea on exertion

negative shortness of breath, cough, sputum production

no cough or difficulty breathing

no hemoptysis

no hiccups

no history of pulmonary TB

no pleurisy

no PND or orthopnea

there was good respiratory effort

chest pressure

denies history of heart attack

denies night cramps

denies orthostasis

denies substernal or radiating chest pain

negative chest pain on exertion or palpation

no angina

No chest pain, chest pressure, chest discomfort

no history of valve disease

no palpitations or syncope

no precordial pain

No squeezing, strangling, tightness, heaviness or aching about the chest, neck or axilla

positive/negative for hypertension

bright red blood per rectum

denies abdominal fullness

denies black tarry stools

has GERD

melena

no abdominal pain or blood

no acid reflux, heartburn

no anorexia

no constipation

No constipation, diarrhea, black stools, bright red blood per rectum

no epigastric pain

no GI bleed

no hematemesis

no hematochezia

no hemorrhoids

no melanotic stools

no melenemesis

no nausea, vomiting or diarrhea

no odynophagia

no rectal bleeding

GENITOURINARY SYSTEM:

anuric

burning on urination

denies any CVA or suprapubic tenderness

denies pregnancy

diminished urine output

flank pain

has vaginal bleeding

history of carcinoma of the prostate

LMP is current

microscopic hematuria

no difficulty urinating

no dysuria, polyuria, frequency, urgency, hesitancy

no female discharge

no gross blood in the urine

no hematuria or dysuria

no incontinence of bowel or bladder

no kidney stones in the past

no nocturia

no pyuria

no urinary retention

no urinary tract infections

on hemodialysis

pregnancy, last menstrual period

urinary incontinence

varicocele

Review of Systems Transcribed Examples

MUSCULOSKELETAL SYSTEM:

no focal joint pain or stiffness

no joint swelling

no muscle pains

no muscle, back pain, joint pain or stiffness

no myalgias or arthralgias

no neck pain or back pain

no trauma

change in level of consciousness

denies any seizures, convulsions, unconsciousness, speech difficulty or ataxia.

difficult to perform because of poor patient cooperation

negative/positive for migraines

no change in bowel or bladder control

no confusion

no focal weakness

no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities

no history of TIA, CVA

no lightheadedness or slurred speech

no motor or sensory loss

no paresthesias, fasciculations, seizures or weakness

no strokes or seizures

numbness and tingling, stocking/glove distribution

no delusions

no depression, no loss of interest in normal activity or change in sleep pattern

no disorder of thought or mood

no hallucinations or suicidal ideations

no history of depression or anxiety

no mania

no change in skin, hair, nails

no dermatitis

no evidence of squamous or basal cell CA

no rash or itching

no skin rash or skin lesions

no unusual skin spots

positive for hives

vesicular lesions

negative for thyroid abnormalities

negative/positive for diabetes

no fibroid abnormalities

no heat or cold intolerance, polyuria or polydipsia

no sweating

denies abnormal bleeding

denies bleeding disorder

negative for anemia or blood dyscrasias

no abnormal hemorrhaging

no anemia

no easy bruisability

no easy bruising or bleeding

no history of blood clots

no unusual infections or bleeding

no enlarged nodes

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