Review of Systems Medical Transcription Samples / Examples for Medical Transcriptionists

REVIEW OF SYSTEMS:  Extensive 14-point review of systems was performed. Essentially, he has a concern of a left cataract, but no other ocular disease. No history of recurrent sinus infections or problems. No history of hearing or recurrent ear infections. No history of major dental problems. He also has no history of hypothyroidism, neck masses or lesions. No history of hemoptysis, although he is having sputum production at this time.  He has no history of tuberculosis or positive PPD. No history of anginal-type pains or chest symptoms and no previous cardiac catheterizations or ED visits. No history of hemoptysis or hematemesis.  He has no history of back pain or CVA tenderness. He had previous orthopedic surgery but no ongoing complaints or symptoms. He has no dermatologic complaints at this time and specifically denies any rash or significant pruritus. He has no significant tremor or neurologic disorder.

REVIEW OF SYSTEMS:  No fever, no chills, no weight change. Ocular: No drainage, no blurred vision. HEENT:  No sore throat, earache, or congestion. No neck pain. COR:  No chest pain. No palpitations. Lungs:  No shortness of breath or cough. GI:  No nausea, no vomiting, no diarrhea, no constipation, no anorexia. GU:  No dysuria, frequency, or urgency. No hematuria. No vaginal discharge or vaginal bleeding. Musculoskeletal:  No joint pain or swelling or edema. Skin:  No rash or itching. Psychiatric:  No anxiety, no depression. Endocrine:  No polyuria or polydipsia.

REVIEW OF SYSTEMS:  Please see the HPI for neurologic and other pertinent review of systems.  Otherwise, the following systems are noncontributory including constitutional, eyes, ears, nose and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin and/or breast, endocrine, hematologic/lymph, allergic/immunologic and psychiatric.

REVIEW OF SYSTEMS:  She reports of discomfort in the chest but denies having  shortness of breath currently.  Denies headache or blurred vision.  Reports having memory problems and forgetfulness.  Denies fever or chills.  Reports no generalized weakness.  No constipation or diarrhea.

REVIEW OF SYSTEMS:  Generally weak, debilitated, somewhat dyspneic on mild exertion. He has a full productive cough, which is congested without hemoptysis . He has low-grade fevers as well as has had chills or rigors. Mildly dyspneic. Without chest pain. No diarrhea, dysuria, hematuria, skin rash or leg pain.  He is not noted to have thrombophlebitis or pulmonary emboli. Has some residual incisional pain in his right shoulder.

REVIEW OF SYSTEMS:  Denies chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg edema, leg pain, leg trauma, dizziness or palpitations. Remainder of review of systems including the head, neck, chest, abdomen, extremities and neurological systems negative.

REVIEW OF SYSTEMS:  Constitutional:  Denies any recent rigors or sweats.  Pulmonary:  As noted above.  Cardiac:  As noted above.  Gastrointestinal:  Does complain of some lower left quadrant abdominal pain.  Denies any nausea, vomiting, diarrhea, melena or hematochezia.  Genitourinary:  Denies any dysuria, hematuria or polyuria.  Hematologic:  Denies any history of anemia or bleeding diathesis.  Endocrine:  No history of thyroid disease.  Diabetes as noted above.  Vascular:  Denies any history of DVTs or PE.  Musculoskeletal:  Unremarkable.  Neurologic:  As noted above.  Psychiatric:  History of depression.

ROS Examples # 1           

REVIEW OF SYSTEMS:  CONSTITUTIONAL: No fevers, chills or change in weight. EYES: No diplopia or blurred vision. ENT: No earache, sore throat or runny nose. CARDIOVASCULAR: No pressure, squeezing, tightness, heaviness or aching about the chest, neck, axilla or epigastrium. RESPIRATORY: No cough, shortness of breath, PND, or orthopnea. GASTROINTESTINAL: No nausea, vomiting, or diarrhea. GENITOURINARY: No dysuria, frequency or urgency. MUSCULOSKELETAL: As per HPI. SKIN: No change in skin, hair or nails. NEUROLOGIC: No paresthesias, fasciculations, seizures or weakness. PSYCHIATRIC: No disorder of thought or mood. ENDOCRINE: No heat or cold intolerance, polyuria or polydipsia. HEMATOLOGICAL: No easy bruising or bleeding. 

REVIEW OF SYSTEMS:  She reports of some discomfort in the chest area, but no shortness of breath, no headaches, no blurry vision, no diarrhea, no constipation, but reports of some nausea at times.  No fever or chills.  No headaches.

REVIEW OF SYSTEMS:  Denies any significant changes in weight or appetite.  No fever.  Respiratory:  No COPD, no known respiratory tuberculosis.  Cardiovascular:  Hypertension.  No MI.  Endocrine:  No thyroid disease or history of diabetes.  As per above.  Rheumatological:  As per above.  Neurological:  No CVA, TIA or seizures.  Hematological:  Coagulopathy as per above.  Gastrointestinal:  Cirrhosis, no history of hepatitis or pancreatitis.

ROS Examples # 2          

REVIEW OF SYSTEMS:  She denies any fevers, chills, night sweats. No nausea, vomiting, diarrhea, dysuria, hematuria or pyuria. No bright red blood per rectum. No melena. No constipation. No diarrhea. No vaginal spotting or bleeding. No PND, orthopnea or lower extremity edema. No chest pain. No exertional chest pain, nausea, jaw pain or arm pain. She has significant right shoulder pain with full range of motion from her adhesive capsulitis and is doing physical therapy and seeing a chiropractor for this regularly. She has been evaluated by an outside orthopedist and would like a second opinion here. She feels her ability to recall words is somewhat diminished but denies any other problems with memory. Her eyes seem somewhat blurry. She was told she had cataracts by her ophthalmologist and is returning there for repeat testing.

REVIEW OF SYSTEMS:  Neurological:  No headaches or dizziness. No fainting. Cardiovascular:  No chest pain or palpitations. Respiratory:  Had bronchitis in high school. No asthma or pneumonia. States sometimes, when she feels anxious, she feels like she cannot breathe but knows she can. She is able to exercise without any difficulty. Gastrointestinal:  Appetite is good. No nausea, vomiting, diarrhea, occasional constipation. She states occasionally if she has been straining, she might see a little blood present, but no bloody stools. No history of colon cancer in the family. Genitourinary:  No burning, urgency or frequency. Gynecologic:  Followed by Gynecology. Last Pap smear was in July (XXXX). Musculoskeletal:  Without complaints. Eyes:  She has regular eye exam. She wears contacts and glasses. Dentist:  She sees regularly.

REVIEW OF SYSTEMS:  He denies recent fever or chills.  Admits to diaphoresis last night.  He states he had recent hemoptysis, which has resolved.  His cardiac history is as stated above.  He had some mild abdominal pain with body aches this morning, which has resolved.  Denies blood in the stool or urine.  He has a history of mild depression.  No history of syncope, stroke or seizure.

REVIEW OF SYSTEMS:  No acute eyes, nose or throat complaints.  He does at times have cough productive of phlegm.  He states in humid weather he has more difficulties.  He is being treated for hyperlipidemia.  He has coronary artery disease.  He denies tuberculosis or pneumonia.  He does relate he has COPD.  Cardiovascular:  As noted in the history of present illness.  No specific history of rheumatic fever or valvular heart disease.  Previous history of myocardial infarction.  Gastrointestinal:  He has been treated for peptic ulcer disease in the past.  He has had cholelithiasis and subsequently he has had laparoscopic cholecystectomy as well as ERCP.  He has remote history for nephrolithiasis with lithotripsy and current GU symptoms.  Musculoskeletal:  As noted with cervical spine disk disease and he has had previous diskectomy and laminectomy.  There is no history of strokes or seizure disorders.  No history for skin or soft tissue infections.

ROS Words and Phrases            

REVIEW OF SYSTEMS:  The patient does not have any history of seizure.  She denies any sore throat.  No dysphagia.  No history of tuberculosis.  No history of hepatitis.  No dysuria or hematuria.  At this time, no severe arthralgia or myalgia.  No generalized rash or pruritus.  No personal history of cancer.

REVIEW OF SYSTEMS:  General:  No fever, chills or weight loss.  Cardiovascular:  Chest pain as previously noted.  No complaint of palpitations.  Respiratory:  No PND or orthopnea.  No dyspnea on exertion.  Gastrointestinal:  No nausea or vomiting.   No blood in bowel movements or dark tarry stools.  Genitourinary:  No dysuria or hematuria.  Neurological:  No TIA or CVA symptoms.

REVIEW OF SYSTEMS:  No recent fever, chills, weight loss. ENT:  No sore throat, ear pain. CARDIOVASCULAR:  No precordial pain. RESPIRATORY: No cough or hemoptysis. GASTROINTESTINAL: No nausea, vomiting or diarrhea. GENITOURINARY: No dysuria. No polyuria or polydipsia. HEMATOLOGIC:  No easy bruisability. SKIN:  No itching. NEUROLOGIC:  Seizure tonight and seizures on somewhat irregular basis.  There is no numbness, tingling or paresthesias.

REVIEW OF SYSTEMS:  EYES:  No double vision, blurred vision, visual loss. ENT:  No ear pain, congestion, sore throat or sinus disease. CARDIOVASCULAR:  Positive history of hypertension. PULMONARY:  See present medical history. GASTROINTESTINAL:  No nausea, vomiting or diarrhea. GENITOURINARY:  No dysuria or hematuria. MUSCULOSKELETAL:  No arthritis, joint pain or swelling. SKIN:  No eczema, psoriasis or other chronic skin disorder. NEUROLOGIC:  No seizure, strokes, focal motor abnormalities or paresthesias. ENDOCRINE:  Negative for diabetes. No adrenal or thyroid abnormalities. HEMATOLOGICAL:  No anemia or bleeding dyscrasias.

REVIEW OF SYSTEMS:  CONSTITUTIONAL: No fevers, chills or change in weight. EYES: No diplopia or blurred vision.  ENT: No earache, sore throat or runny nose.  CARDIOVASCULAR:  Atrial fibrillation.  RESPIRATORY:  No cough, shortness of breath, PND or orthopnea.  GASTROINTESTINAL:  No nausea, vomiting or diarrhea.  GENITOURINARY:  No dysuria, frequency or urgency.  MUSCULOSKELETAL:  No myalgias or arthralgias.  SKIN:  No change in skin, hair or nails.  NEUROLOGIC:  No paresthesias, fasciculations, seizures or weakness.  PSYCHIATRIC:  As per HPI.  ENDOCRINE:  No heat or cold intolerance, polyuria or polydipsia.  HEMATOLOGICAL:  No easy bruising or bleeding.

REVIEW OF SYSTEMS:  Other than symptoms attributable to the present illness and past history as described above, general review of systems is otherwise negative.  GENERAL:  No change in appetite, energy or weight.  No fever, chills or sweats.  No history or symptoms of hyper or hypothyroidism.  HEMATOLOGIC:  No history of anemia, easy bruising, bleeding or clotting disorders.  HEAD AND NECK:  No auditory or visual complaints.  No tinnitus.  No pharyngeal complaints.  RESPIRATORY:  Denies any cough, asthma, bronchitis or wheezing.  CARDIOVASCULAR:  As above.  GASTROINTESTINAL:  No dysphagia, odynophagia, acid regurgitation, heartburn, indigestion, diarrhea or constipation.  No history of nausea or vomiting.  No change in appearance, frequency or consistency of bowel movements.  MUSCULOSKELETAL:  No myalgias, arthralgias, joint swelling.  NEUROLOGICAL:  No vertigo or disturbance of balance or coordination.  No motor or sensory complaints.  GENITOURINARY:  No dysuria, urgency or urinary frequency.  No incontinence.  No history of kidney problems. DERMATOLOGIC:  No complaint of skin lesions or rashes.  No change in nails or hair.  PSYCHIATRIC:  No noted disturbance in mood or cognitive function.

ROS Examples # 3   

REVIEW OF SYSTEMS:  GENERAL:  No fevers or chills.  HEENT:  No change in vision, no earache, sore throat 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 or 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:  No fever or weight loss.  EYES:  No change in vision.  EARS:  No change in hearing.  NOSE:  No epistaxis or rhinorrhea.  MOUTH:  No sore throat.  NECK:  No neck pain.  CARDIOVASCULAR:  No chest pain.  LUNGS:  Positive cough, dry, nonproductive.  No shortness of breath.  ABDOMEN:  No nausea, vomiting, diarrhea or abdominal pain.  GENITOURINARY:  No dysuria or frequency.  EXTREMITIES:  No joint swelling.  NEUROLOGIC:  No focal weakness.  Generalized weakness.  Positive dizziness.  No headache.  SKIN:  No rashes.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  No fever.  EYES:  No blurry vision or double vision.  ENT:  No sore throat or earache.  RESPIRATORY:  No cough or wheezing.  CARDIOVASCULAR:  No chest pain or palpitations.  GASTROINTESTINAL:  No nausea, vomiting, no diarrhea, no rectal bleeding, no melanotic stools.  GENITOURINARY:  No hematuria or dysuria.  She has had no vaginal bleeding.  NEUROLOGIC:  No syncope or seizure.  MUSCULOSKELETAL:  No joint pain or stiffness.  SKIN:  No rash.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  Negative fever or chills.  EYES:  Negative visual field deficit or double vision.  ENT:  Positive for sore throat and runny nose.  PULMONARY:  Negative shortness of breath.  Positive for cough.  Negative for sputum production.  CARDIOVASCULAR:  Positive for chest pain.  Negative chest pain on exertion.  Positive for palpitations.  GASTROINTESTINAL:  Negative nausea, vomiting or diarrhea, abdominal pain.  GENITOURINARY:  Negative frequency, urgency or dysuria.  ENDOCRINE:  Negative polyuria or polydipsia.  HEMATOLOGY AND ONCOLOGY:  No unusual infections or bleeding.  NEUROLOGICAL:  No headache or confusion.

REVIEW OF SYSTEMS:  CONSTITUTIONAL: No fever. No chills. No dizziness. No weakness.  EYES: No pain, erythema, or discharge. No blurring of vision. EAR, NOSE AND THROAT: 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, or 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. METABOLIC: No fatigue. No weakness. No history of thyroid, diabetes or adrenal problems. HEMATOLOGICAL: No bleeding. No petechiae. No bruising. ALLERGY: No asthma. No urticaria.

REVIEW OF SYSTEMS:  The patient denies any fever, chills, nausea, vomiting, dizziness, headache, blurry vision, eye pain, eye drainage, ear pain, ear drainage, hearing loss, nasal drainage, nasal lesions, epistaxis, sore throat, difficulty swallowing, heartburn, indigestion, chest pain, shortness of breath, heart palpitations, orthopnea, dyspnea on exertion, abdominal discomfort, constipation, diarrhea, dysuria, or frequency with urination.

REVIEW OF SYSTEMS:  The patient denies any acute hair, nail or skin changes, weight changes, heat or cold intolerance.  No palpitations, dyspnea or dyspnea with exertion, orthopnea, and no acute bladder or bowel changes, polyuria, dysuria, change in color or consistency of stool.

REVIEW OF SYSTEMS:  He denies any frequent headaches or double vision.  He denies any prior history of chest pain, shortness of breath, constipation, diarrhea, bloody or black stool, weakness or numbness.

REVIEW OF SYSTEMS:  On comprehensive review of systems, she has positive cardiac complaints, positive pulmonary complaints, positive GI complaints, positive constitutional complaints, negative endocrine, negative skin, negative neurologic, and negative GYN or urologic complaints.

REVIEW OF SYSTEMS:  Negative for weight changes, nausea, vomiting, headache, blurred vision.  Positive for recent ataxia and generalized lower extremity weakness.  Positive for change in bowel habits over the last year.

REVIEW OF SYSTEMS:  HEENT:  He has progressive lenses.  Hearing is fine.  Cardiovascular:  No chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea or claudication.  Respiratory:  No fever, night sweats, chills, cough or shortness of breath.  Gastrointestinal:  Appetite diminished.  Right flank pain.  Genitourinary:  No dysuria, frequency or hematuria.  Musculoskeletal:  No bone pain except for some mild arthritis.  Neurologic:  No focal weakness.  The patient has had headaches over the past several weeks, primarily frontal.  They are intermittent.  There has been no focal weakness.

REVIEW OF SYSTEMS:  He denies any history of known atrial fibrillation or cardiac arrhythmia, renal, hepatic, pulmonary disease, thyroid disease, lupus, GI bleeding, ulcer, cancer, seizure or strokes.

ROS Examples # 4

REVIEW OF SYSTEMS:  She denies any unusual headaches.  No blurred vision, no double vision, no eye pain, no eye discharge, no earache, no ear discharge, no vertigo, no nasal pain or nasal discharge, no epistaxis, no oral pain, no tongue soreness.  No diaphoresis.  No chills.  No difficulty breathing.  No palpitations.  No nausea.  No vomiting.  No dysuria.  No hematuria.  No ankle swelling.  No rash.  No itching.  No depression.

REVIEW OF SYSTEMS:  Denies any history of focal weakness.  No blurred vision, no double vision, no eye pain, no eye discharge, no earache, no ear discharge, no unusual headaches.  No vertigo, however she did have some dizziness and generalized weakness.  No nasal pain, no nasal discharge, no epistaxis, no oral pain, no tongue soreness.  She did have vomiting of blood.  No neck pain.  No chest pain.  No difficulty breathing.  No palpitations.  She did have some nausea and vomiting as mentioned above.  No abdominal pain.  No dysuria or hematuria.  She had black tarry stools.  She gets occasional ankle swelling.  No rash.  No itching.  No depression.  She has anxiety.

REVIEW OF SYSTEMS:  No weight loss, fever or chills.  Cardiopulmonary:  No chest pain, palpitations or shortness of breath.  Endocrinology:  No heat or cold intolerance.  ENT:  No sore throat or hearing loss.  Gastrointestinal:  See above.  Genitourinary:  No dysuria or hematuria.  Musculoskeletal:  Some back pain and leg pain at this time.  Neurologic:  No headache or seizures.  Hematologic:  No bleeding disorders.

ROS Examples # 5

REVIEW OF SYSTEMS:  Denies any fever, cough, cold, headache, visual loss, neck pain, chest pain, palpitations, shortness of breath, abdominal pain, new weakness, focal weakness, gait problems or bowel or bladder changes.

REVIEW OF SYSTEMS:  No pharyngitis, rhinorrhea, headache or dizziness.  The patient did not complain of any chest pain.  She was short of breath.  There is a history of diarrhea.  There is no hematuria.  There is no history of diabetes or thyroid disorder.  There is a history of anemia but no bleeding disorder.  There is a history of weight loss.

REVIEW OF SYSTEMS:  The patient is not aware of any personal history of stroke or seizure.  No history of thyroid disease or goiter.  No history of diabetes mellitus.  No history of tuberculosis.  No active cough or sputum production at this time.  No history of hepatitis.  No history of gallstones.  He is not aware of any personal history of cancer.  No history of deep vein thrombosis.  No generalized rash, although he did have previous episode of cellulitis of left lower extremity.