What symptoms should be included in the chart note for review?

From the Guidelines

A comprehensive review of symptoms (ROS) in a chart note should include both positive and negative findings across all major body systems, prioritizing the most recent and highest quality study available, such as the 2022 ACC/AHA key data elements and definitions for chest pain and acute myocardial infarction 1. When documenting symptoms, it is essential to consider the nature and character of the symptoms, such as chest pain, which can be described as burning, dull, heaviness, pressure, sharp, squeezing, stabbing, tearing, or tightness, as outlined in the 2022 ACC/AHA guidelines 1. The review of symptoms should begin with constitutional symptoms like fever, weight changes, and fatigue, and then proceed systematically through each system, including:

• Head/eyes/ears/nose/throat (headaches, vision changes, hearing issues, sinus problems, sore throat)
• Cardiovascular (chest pain, palpitations, edema)
• Respiratory (cough, shortness of breath, wheezing)
• Gastrointestinal (abdominal pain, nausea, vomiting, diarrhea, constipation)
• Genitourinary (urinary frequency, dysuria, hematuria)
• Musculoskeletal (joint pain, muscle weakness, back pain)
• Neurological (dizziness, numbness, weakness, seizures)
• Psychiatric (mood changes, anxiety, depression)
• Endocrine (heat/cold intolerance, excessive thirst)
• Hematologic/lymphatic (easy bruising, bleeding, swollen glands)
• Allergic/immunologic (rashes, allergies, recurrent infections) It is also important to consider the patient's emotional, physical, and general wellbeing, as well as any history of physical or mental health issues, as recommended in the 2024 Lancet Global Health study 1. Additionally, the 2012 Annals of Oncology study 1 and the 2021 Journal of Neurology, Neurosurgery and Psychiatry study 1 provide further guidance on assessing and managing symptoms, including pain, swallowing, and communication disorders. By following a systematic approach to documenting symptoms, healthcare providers can ensure thorough evaluation, identify additional concerns beyond the chief complaint, and provide baseline information for future comparison, ultimately supporting clinical decision-making and improving patient outcomes 1.

From the FDA Drug Label

USES For Arthritis Pain label • temporarily relieves minor aches and pains due to: • minor pain of arthritis • muscular aches • backache • premenstrual and menstrual cramps • the common cold • headache • toothache • temporarily reduces fever ADVERSE REACTIONS The most frequent type of adverse reaction occurring with ibuprofen tablets is gastrointestinal. In controlled clinical trials the percentage of patients reporting one or more gastrointestinal complaints ranged from 4% to 16%

The symptoms to include in the chart note are:

• Muscular aches
• Backache
• Headache
• Toothache
• Premenstrual and menstrual cramps
• Common cold
• Gastrointestinal complaints 2 3

From the Research

Symptoms to Include in Chart Note

When reviewing symptoms to include in a chart note for patients experiencing headaches, several key points should be considered:

• The classification of the headache as a primary or secondary headache disorder, as this distinction guides treatment and management decisions 4
• The presence of symptoms or signs that suggest an urgent medical problem, such as abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes 4
• The severity and frequency of the headaches, as well as any triggers or alleviating factors 5
• The patient's response to previous treatments, including any adverse effects or lack of efficacy 6, 7
• The presence of any comorbid conditions, such as cardiovascular disease, that may impact treatment choices 4, 8

Key Symptoms and Signs

Some key symptoms and signs to include in the chart note are:

• Location, quality, and severity of the headache pain
• Presence of any accompanying symptoms, such as nausea, vomiting, or sensitivity to light and sound
• Timing and duration of the headache
• Any triggers or factors that exacerbate or alleviate the headache
• Presence of any neurologic signs, such as weakness, numbness, or tingling
• Patient's medical history, including any previous diagnoses or treatments for headache disorders

Treatment Considerations

When considering treatment options, the following points should be taken into account:

• The use of acute treatments, such as triptans, nonsteroidal anti-inflammatory drugs, and combination products, for the management of migraine attacks 4, 5, 7, 8
• The potential for medication overuse headache and the need to limit the use of acute treatments to a maximum of ten days per month 6
• The use of preventive treatments, such as antihypertensives, antiepileptics, antidepressants, and calcitonin gene-related peptide monoclonal antibodies, for patients with frequent or severe headaches 4, 7