Review of Systems Question

[njslex16]

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I was wondering if anyone could help me out with an H&P writeup question that I've been having for a while. In the section for the Review of Systems, when going through each system and asking the pertinent associated questions, are past history/symptoms relevant or should they just pertain to the reason/chief complain that the pt came to the hospital for in the first place? For example, during the ROS when I asked a pt who came in with lower back and bone pain about her cardiovasc. system, she mentioned that she thought she was diagnosed with possible mitral valve prolapse nearly a decade ago. But in terms of this admission, she had denied all cardiac sx. So should I include this hx of mitral valve prolapse in the ROS, even though it very likely has nothing to do with this patient's current hospital admission? Sorry if that was confusing. Also if anyone has a great writeup template for a full H&P and could share it, I would greatly appreciate it.

 

[turkeyjerky]

I would include the ?h/o MVP in the PMHx. Then document cardiac ROS as negative. In general, you have to exercise a lot of judgement in documenting the ROS, as some patients will tend to provide a ton of vague, extraneous symptoms in response to your questions.

 

[VisionaryTics]

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[armybound]

Agreed, it's medical history, not ROS.

The patient can tell you they've had 40 MIs but if they aren't experiencing chest pain, it doesn't go in the ROS.