Chapter 2: Review of Systems

INTRODUCTION

The review of systems (or symptoms) (ROS) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area. It can be applied in several ways:

• As a screening tool asked of every patient that the clinician encounters

• Asked only of patients who have specific risk factors or symptoms or who present with certain clinical scenarios

Is it appropriate (as is frequently done) to perform the same ROS on all patients as a screening tool? Using the ROS in this fashion would make sense if all of the following hold true:

• The questions have the potential to uncover an array of common and important clinical conditions.

• These disorders would go unrecognized if the patient was not specifically prompted.

• The identification of these conditions through an ROS would have a positive impact on morbidity and/or mortality.

There is no evidence to support these assumptions. In fact, positive responses to a broadly applied screening ROS are often of unclear significance and may even create problems by generating a wave of additional questions (and testing) that can be of low yield. For these reasons, it is better to incorporate a more targeted and thoughtful approach to ROS questions based on patient-specific characteristics, risk factors, clinical scenarios, and symptoms. For example:

• ROS questions designed to uncover occult disease of the prostate can be asked of men over 50.

• A cardiovascular ROS can be used when caring for patients who have risk factors for atherosclerotic disease, such as diabetes and hypertension.

• A multisystem ROS can be used when patients present with nonspecific symptoms, such as fever without focality, fatigue, or weight loss.

If a patient feels well and has neither risk factors nor symptoms, then no ROS would be necessary. This approach is likely to be both more efficient and revealing.

It is important to recognize that positive responses to an ROS query will require follow-up questions. For example, if a patient responds “yes” to an ROS question about chest pain, you will then need to ask additional questions to further define the core dimensions of this symptom. These are described in the history of present illness (HPI) section of Chapter 1.

There is no ROS gold standard. The breadth of questions that follows is based on commonly occurring illnesses and symptoms. There is planned redundancy because the same symptoms often apply to multiple organ systems (eg, chest pain could be of cardiac, pulmonary, gastrointestinal, or musculoskeletal etiology). The reason for gaining familiarity with these ROS questions is so that you can use them during situations where you believe they are appropriate. With experience and consideration, you will identify the questions that fit your clinical needs and gain facility with how to apply them in a way that is consistent with your overall patient care ...