REVIEW OF SYSTEMS (ROS)
- Constitutional Symptoms: [Describe any generalized symptoms such as fever, chills, fatigue, malaise, weight changes, or night sweats. Include details on onset, frequency, severity, and any associated factors. If not mentioned, omit this section.]
- Eyes: [Document any eye-related symptoms such as vision changes, eye pain, redness, discharge, photophobia, excessive tearing, dryness, or itching. Include duration, severity, and any modifying factors. If not mentioned, omit this section.]
- Ears, Nose, Mouth, and Throat:
- Ears: [Describe any auditory symptoms, including hearing loss, tinnitus, ear pain, discharge, or vertigo. Include details on the onset, severity, and any contributing factors. If not mentioned, omit this section.]
- Nose: [Document nasal symptoms such as congestion, rhinorrhea, nosebleeds, sinus pain, or postnasal drip. Specify frequency, severity, and any known triggers. If not mentioned, omit this section.]
- Mouth and Throat: [Describe symptoms related to the mouth and throat, including sore throat, hoarseness, oral ulcers, dry mouth, dental pain, gum bleeding/swelling, or difficulty swallowing. Include onset, severity, and any aggravating or relieving factors. If not mentioned, omit this section.]
- Cardiovascular: [Document any cardiovascular symptoms such as chest pain, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, or syncope. Include details on duration, frequency, and any triggering or relieving factors. If not mentioned, omit this section.]
- Respiratory: [Describe any respiratory symptoms such as cough, sputum production, hemoptysis, shortness of breath, wheezing, or chest tightness. Specify onset, duration, severity, and any modifying factors. If not mentioned, omit this section.]
- Gastrointestinal: [Document symptoms related to digestion, including nausea, vomiting, abdominal pain, diarrhea, constipation, heartburn, bloating, hematemesis, melena, hematochezia, or appetite changes. Include onset, severity, frequency, and any aggravating or relieving factors. If not mentioned, omit this section.]
- Genitourinary:
- Urinary Symptoms: [Describe any urinary complaints such as dysuria, frequency, urgency, nocturia, hematuria, incontinence, or flank pain. Specify onset, severity, and any associated factors. If not mentioned, omit this section.]
- Reproductive Symptoms:
- Male: [Document symptoms such as erectile dysfunction or testicular pain/swelling. Include onset, severity, and any modifying factors. If not mentioned, omit this section.]
- Female: [Describe symptoms such as abnormal vaginal discharge, menstrual irregularities, dyspareunia, or menopausal symptoms such as hot flashes or night sweats. Include duration, severity, and any associated changes. If not mentioned, omit this section.]
- Musculoskeletal: [Document any symptoms such as joint pain/swelling, muscle weakness, myalgias, stiffness, back pain, or difficulty ambulating. Specify affected areas, severity, duration, and any modifying factors. If not mentioned, omit this section.]
- Integumentary (Skin and/or Breast):
- Skin: [Describe any skin-related symptoms such as rash, pruritus, lesions, color changes, or hair/nail abnormalities. Include onset, duration, and severity. If not mentioned, omit this section.]
- Breast: [Document any breast-related symptoms such as lumps, pain, nipple discharge, or skin changes. Specify duration and any associated factors. If not mentioned, omit this section.]
- Neurological: [Describe any neurological symptoms such as headaches, dizziness, numbness, tingling, weakness, seizures, tremors, coordination difficulties, memory loss, or speech disturbances. Specify onset, severity, and any known triggers. If not mentioned, omit this section.]
- Psychiatric: [Document any psychiatric symptoms such as depression, anxiety, insomnia, hallucinations, suicidal ideation, or homicidal ideation. Include onset, severity, and impact on daily life. If not mentioned, omit this section.]
- Endocrine: [Describe any endocrine symptoms such as heat/cold intolerance, unintentional weight changes, polyuria, polydipsia, hair thinning/loss, or libido changes. Include onset, frequency, and severity. If not mentioned, omit this section.]
- Hematologic/Lymphatic: [Indicate whether the patient has experienced any hematologic or lymphatic symptoms, including bleeding tendencies or swollen lymph nodes. If symptoms are present, describe severity and frequency. If not mentioned, omit this section.]
- Allergic/Immunologic: [Describe any allergic or immunologic symptoms such as seasonal allergies, food allergies, anaphylaxis history, recurrent infections, or unexplained fevers. Include onset, severity, and any known triggers. If not mentioned, omit this section.]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information is not available; simply leave the placeholder blank or omit it completely. Use as many lines, paragraphs, or bullet points as necessary to comprehensively capture all relevant details.)