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Review of Systems Medical Transcription Examples

REVIEW OF SYSTEMS:  Constitutional:  Positive for weight gain, which the patient associates with abdominal bloating.  Positive for night sweats.  Negative for fever.  Head/Neck:  Negative for visual changes, hearing changes, hoarseness, sore throat or nasal problems.  Respiratory:  Positive for shortness of breath.  Negative for asthma or emphysema.  Cardiovascular:  Denies hypertension or coronary artery disease.  Gastrointestinal:  She has had abdominal pain with bloating.  She describes nausea.  She denies vomiting.  Denies diarrhea or constipation.  Denies hepatic disease.  Genitourinary:  Negative for renal dysfunction, dysuria or urinary frequency.  Hematologic:  She has sickle cell anemia.  She apparently had multiple transfusions resulting in iron overload and is being treated for this.  Allergic/Immunologic:  Negative for allergic or immunologic phenomenon.  Infectious:  Denies any infectious disease processes.  Endocrinology:  Negative for diabetes mellitus or thyroid dysfunction.  Musculoskeletal:  She describes occasional mid back pain.  Neurologic:  Positive for headache.  Negative for seizures or strokes.  Psychiatric:  She describes some anxiety.  Denies depression.  Dermatologic:  Denies skin conditions.

REVIEW OF SYSTEMS:  No history of seizures.  No history of chest pain, shortness of breath, angina or dysphagia.  Prior to this episode, no history of early satiety, no history of significant weight loss, no history of hematuria, no history of hematemesis, and no history of melena.

REVIEW OF SYSTEMS:  No fever.  No chills.  Skin:  No rash.  ENT:  No sore throat.  CVS:  No chest pain.  No palpitation.  Respiratory:  No shortness of breath.  GI:  No nausea, vomiting, diarrhea or constipation.  No abdominal pain.  GU:  No dysuria.  Neuropsychiatric:  No depression or anxiety.

REVIEW OF SYSTEMS:  General:  Denies chronic fever, chills, weight loss or decreased energy.  Cardiac:  Denies MI, palpitations and does have hypertension.  Respiratory:  Denies chronic cough, shortness of breath or asthma.  GI:  Denies chronic abdominal pain.  All other systems reviewed are negative.

REVIEW OF SYSTEMS:  No lightheadedness, dizziness, presyncope or syncope.  No headache or visual changes.  No nausea, vomiting, melena, bright red blood per rectum, flank pain, hematuria or dysuria.  Review of systems is otherwise as listed in the history of present illness or otherwise negative.

REVIEW OF SYSTEMS: Constitutional: Positive for fatigue. Negative for fever, chills, rigor, night sweats, weight gain or weight loss. HEENT: Negative for hoarseness, sore throat, visual disturbance or epistaxis. Cardiovascular: Positive for chest pain but negative for palpitations or pedal edema. Respiratory: Positive for previous tobacco abuse, positive for dyspnea, no nocturnal asthma, PND, orthopnea or hemoptysis. Genitourinary: Negative for nocturia, dysuria, hematuria or nephrolithiasis. Gastrointestinal: Positive for indigestion but no abdominal pain, nausea, vomiting, constipation, diarrhea, hematochezia or melena. Endocrine: Negative for polyuria, polydipsia, heat or cold intolerance, skin changes, weight gain or weight loss. Dermatologic: Negative for rash, hives or ulceration. Musculoskeletal: Positive for joint stiffness and dysarthria. Hematologic: Positive for easy bruising but no known hemophilia, anemia  or previous blood transfusion. Psychiatric: Negative for sleep disorder, anxiety, depression or mental illness. Neurologic: Negative for headache, seizure or syncope.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  Positive for subjective fever per patient yesterday, which has resolved. HEENT:  Negative for vision changes or conjunctival injection or drainage from the eye. Mild throat discomfort that started today. Otherwise, no neck pain. CARDIOVASCULAR:  No chest pain or palpitations noted per patient. RESPIRATORY:  No shortness of breath. Positive cough, nonproductive. Negative for wheezing. GASTROINTESTINAL: Negative for current nausea. Positive nausea yesterday, which has resolved. Negative for abdominal pain. Negative for emesis or diarrhea. GENITOURINARY:  Negative for dysuria. MUSCULOSKELETAL:  Positive for some muscular tenderness around his rib cage. Otherwise, negative for any extremity pain.

REVIEW OF SYSTEMS:  GENERAL: Positive for fever, chills, malaise, and weakness. HEENT: Sore throat. No change in vision, no earache, or sinus congestion. NECK: No pain or stiffness. CARDIOVASCULAR: No chest pain or pressure. No palpitations. PULMONARY: No shortness of breath, cough or wheeze. GASTROINTESTINAL: No abdominal pain, nausea, vomiting, diarrhea, melena or bright red blood per rectum. GENITOURINARY: No urinary frequency, urgency, hesitancy or dysuria. MUSCULOSKELETAL: No joint or muscle pain, no back pain, no recent trauma. DERMATOLOGIC: No rash, no itching, no lesions. ENDOCRINE: No polyuria, polydipsia, no heat or cold intolerance. No recent change in weight. HEMATOLOGICAL: No anemia or easy bruising or bleeding. NEUROLOGIC: No headache, seizures, numbness, tingling or weakness. PSYCHIATRIC: No depression, no loss of interest in normal activity or change in sleep pattern.

REVIEW OF SYSTEMS:  Constitutional:  Positive for weight loss, night sweats and fever. Head and Neck:  He wears glasses and is blind in the left eye. He denies hoarseness or sore throat. Positive for poor hearing. Negative for nasal problems. Cardiovascular:  Positive for hypertension, negative for coronary artery disease. Respiratory:  Negative for shortness of breath, cough, asthma or emphysema. Gastrointestinal:  Positive for constipation. Negative abdominal pain, nausea, vomiting, diarrhea or hepatic disease. Genitourinary:  Negative for renal dysfunction, dysuria or urinary frequency. Hematologic:  Positive for anemia and thrombocytopenia. Immunologic/Allergic:  Positive for prostate cancer. Infectious:  He has been having intermittent fevers. Endocrinology:  Positive for diabetes mellitus. Negative for thyroid dysfunction. Musculoskeletal:  Positive for low back and left lower extremity pain. Neurologic:  Denies seizures, strokes or headaches. Some numbness in the left lower extremity, as discussed in history of present illness. Psychiatric:  Denies anxiety or depression. Dermatologic:  Denies skin conditions.

REVIEW OF SYSTEMS:  ENT:  Denies headache, diplopia, blurred vision, loss of visual field or hearing loss, tinnitus, sinusitis or sore throat.  Cardiac:  Denies chest pain, pressure or palpitations.  Pulmonary:  Complains of progressive shortness of breath with associated wheezes as described above.  Denies cough, sputum production or hemoptysis.  Gastrointestinal:  Denies nausea, vomiting, constipation, diarrhea, hematochezia or hematemesis.  Genitourinary:  Denies dysuria, hematuria, nocturia, frequency or polyuria.  Neurologic:  Denies syncope, seizures, vertigo or tremor.

REVIEW OF SYSTEMS:  Significant for night sweats, which he described as drenching.  Positive fatigue, weight loss as indicated before, epistaxis, history of exertional dyspnea, as well as focal chest pain that is intermittent and not particularly associated with exertion.  The patient does have some dull pain in the epigastric region.  Denies melena and denies hematochezia or hemoptysis.  The patient indicates he has had tea-colored urine, as per history of present illness, and some pain in his joints diffusely.  The patient indicates he gets occasionally lightheaded upon standing and nocturia approximately 3 to 4 times per night as previously indicated.

REVIEW OF SYSTEMS:  Endocrine:  History of borderline diabetes, denies thyroid disease.  Pulmonary:  Denies any recent history of pneumonia, asthma, tuberculosis, or hemoptysis.  Cardiac:  Known history of hypertension, hyperlipidemia, presently medically managed .  Denies any prior history of myocardial infarction, PND, orthopnea, scarlet or rheumatic fever.  Gastrointestinal:  History of invasive, poorly differentiated adenocarcinoma with gastric ulceration.  History of metastasis to liver and lesser omentum, status post exploratory laparotomy.  Denies history of jaundice, hepatitis or cirrhosis of liver.  Genitourinary:  Denies difficulty with micturition, hematuria or dysuria.  Musculoskeletal:  Known history of abdominal aortic aneurysm.  History of degenerative joint disease, primarily involving her hands.  Neurological:  Denies history of TIA, CVA or seizure.

REVIEW OF SYSTEMS:  Endocrine:  History of adult-onset diabetes.  He denies thyroid disease.  Pulmonary:  Denies history of recent pneumonia, asthma, tuberculosis or hemoptysis.  Cardiac:  Status post CarboMedics mechanical mitral valve replacement.  On chronic Coumadin therapy.  Known history of coronary artery disease with previous myocardial infarction.  History of multiple recent episodes of unstable angina.  He has a known history of hypertension and hyperlipidemia.  He denies history of rheumatic or scarlet fever.   Gastrointestinal:  Denies present history of hematochezia, reflux, black tarry stools, jaundice, hepatitis or cirrhosis of the liver.  Genitourinary:  Denies difficulty with micturition, hematuria, dysuria or kidney stones.  Musculoskeletal:  Denies disabling arthritis or intermittent claudication.  Neurologic.  Denies past history of stroke or seizure.

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