Review of Systems
Constitutional: + weight loss, + fatigue, + weakness, – fever, – night sweats
Eyes: no pain, redness, vision loss, double vision, gritty feeling in eyes, itchy eyes, eye discharge, eye dryness
ENT: no nasal ulcers/crusting/discharge, mouth ulcers, mouth dryness, new cavities/teeth breaking, hoarseness, dysphagia, swelling in the neck
CV: no palpitations, + chest pain, + shortness of breath, no color changes in fingers upon cold exposure
Lungs: + pleuritic chest pain, no cough, hemoptysis, PND, orthopnea
GI: no nausea, vomiting, hematemesis, dysphagia, heartburn, abdominal pain, diarrhea, blood in stool
GU: no dysuria, hematuria, genital ulcers, polyuria, foamy urine
MSK: + joint pain, no joint swelling, joint locking, inability to bear weight; + joint stiffness ~ 45 min in the morning, no muscle pain or muscle weakness
Neurologic: no headache, vision changes, focal weakness, syncope, dizziness, numbness/tingling, tremors
Skin: +rash after sun exposure on face, upper chest; no painful ulcers, itching, hives, hair loss, dry skin
Endocrine: no polyuria, polydipsia Hematologic: no easy bruising, bleeding
Psychiatric: mood changes, depression, anxiety, cognitive decline, audio or visual hallucinations
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Case 3 Index
Case 3 Introduction