Review of Systems

[GunnerBMS]

I hate asking review of systems questions. The patients always give me wishy-washy answers to the questions. Sometimes, I don't even know if I should include an answer in the hx if the patient is like " Ya, I think I had some night sweating at some point in the last few months." Like, one episode of night sweats if going to catch a cancer diagnosis? How do I know that it wasn't just that they turned the heater on too high one night and that caused the sweats. Also, I don't know how exhaustive I have to be with these questions when talking to patients. How many questions should I ask? Which systems should be covered? On one hand, I was taught ROS should be used to catch things in the history that did not come up in the HPI or the PMHx. However, attendings tell me it should be focused. And, when are these questions pertinent negatives and positives? I just like to ask questions about symptoms that may present in some of my differential diagnoses.

I am just confused and frustrated asking these questions from patients

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[ortnakas]

What year are you?

 

[NickNaylor]

In standardized settings, you should ask a very detailed ROS. In real life, you likely won't have time and it likely won't be necessary to ask an extremely detailed ROS. Granted I'm in psychiatry, but my ROS during clinic visits consists of "any new physical problems over the last couple of weeks?" Of course, I will ask more direct questions about specific symptoms if indicated.

I think it can be helpful to frame the question with what you're expecting. For example, "I'm going to ask you if you've had a series of symptoms, but I only want to know if you've had them during the last [amount of time]." If they tell you about that one time they had a fever 3 months ago, remind them of what you're looking for. Even if you do this, some patients will still provide way more detail than you're looking for and/or fail to actually answer the question in a meaningful way despite providing some kind of answer. In those cases, I would do a very focused ROS to ask about specific symptoms that are critical for you to know. And finally, sometimes it's just not possible to do a quick ROS and you have to bite the bullet and spend the time required to suffer through a slow ROS.

Again, things are different in psychiatry since the physical ROS generally isn't all that important for us, but that's generally my approach.

 

[siliso]

Yup, frame the time course you’re interested in. Let them know you’re asking a bunch of things to be thorough and it’s fine to just say no if they haven’t noticed something recently. Sweats: everyone sweats. I ask if they have to get up and change their clothes/the sheets in the night and how often, that’s the kind of night sweat that would be concerning.

The pertinents are things related or possibly related to the present illness. For instance chest pain: fever, chills, dyspnea, cough, sputum, nausea, diaphoresis, palpitations, dizziness, leg swelling would all be pertinent whether negative or positive. If you’re asking the questions to test any hypothesis about what the problem could be, it’s pertinent. But you’re not expected to be good at this when you start an M3 rotation; it comes with time and feedback.

Some people will have a pan positive review of systems no matter what, and some people are just Talkers who are vague and long winded no matter what, and you have to use your judgment on what to include and when to stop digging.

All of this again gets much easier with time, practice and clinical experience. Now I have a standard 10pt ROS that I can tack on to any H&P in approx 1minute and I do it concurrently with the physical exam.

 

[Psai]

Protips incoming

Rapid fire a bunch of ros at them and be as nonspecific as possible.

End it with a question like "any anal spasms?" to help guide them to the answer you want.

An answer to no for pain gives you negatives for neuro, cardiac, gi, msk, etc.

Don't ask anything that everyone will say yes to such as headache, nausea, etc. unless actually pertinent.

???

Profit

 

[FlowRate]

Protips incoming

Rapid fire a bunch of ros at them and be as nonspecific as possible.

End it with a question like "any anal spasms?" to help guide them to the answer you want.

An answer to no for pain gives you negatives for neuro, cardiac, gi, msk, etc.

Don't ask anything that everyone will say yes to such as headache, nausea, etc. unless actually pertinent.

???

Profit

One of the funniest suggestions I saw on SDN or reddit was to include psych ROS with medical ROS:

"Any fevers, chills, nausea, vomiting, or hallucinations?"
"Any chest pain, shortness of breath, diarrhea, constipation, or thinking that the radio or television are speaking directly to you?"

Turn pan-positive (medical) patient into pan-negative.

 

[NickNaylor]

Protips incoming

Rapid fire a bunch of ros at them and be as nonspecific as possible.

End it with a question like "any anal spasms?" to help guide them to the answer you want.

An answer to no for pain gives you negatives for neuro, cardiac, gi, msk, etc.

Don't ask anything that everyone will say yes to such as headache, nausea, etc. unless actually pertinent.

???

Profit

Psai’s last point about avoiding questions that everyone will say yes to is a very good one. I don’t even bother with asking about headaches unless critical because this will invariably result in a positive answer and if you’re going to be a “good doctor” you will then have to ask follow-up questions. Once you do enough ROS you will start to get a sense for which symptoms always result in a positive response and can start avoiding them unless critical for your assessment.

 

[Anti-PD1]

For OSCEs and CS you have to be robotic.

In real life I'm not going to ask the TBI patient if they have a new skin rash.

With clinical practice, you'll become more targeted and polished.

 

[Redpancreas]

CS=/= Real life, not only in terms of technicalities, but also if you do it that way in real life, you’ll be deemed incompetent as a resident and ultimately fired. ROS needs to be focused, if you can’t make it focused, learn to.

 

[NITRAS]

I ask enough ROS to click the boxed to get the right billing.

 

[operaman]

Yeah I used to hate this part of the encounter too. It definitely gets easier as you develop a better understanding of what's actually important to ask for the given problem, and you'll develop your own personal sauce for a general ROS that covers most other things.

Doing it during your exam is a great time saver and of course you have to be sure to clarify the time course.

Something we do in our clinics is have our patients fill out a ROS sheet (check boxes) while waiting and then we can review that with them and sign it. Then in the note we can say that X systems were reviewed and pertinent post/neg are XYZ, see scanned document for further details, etc., which our coders say meets criteria for highest level billing.

 

[Dares Dareson]

I love doing it on pediatrics.

Fevers? Yes
Chills? Yes
Chest pain? Yes
Difficulty breathing? Yes
Headache? Yes
Double vision? Yes
Body aches? Yes
Night sweats? Yes
Diarrhea? Yes
Constipation? Yes
Urinating frequently? Yes
Not urinating at all? Yes
Vomiting? Yes
Increased appetite, weight gain? Yes
Decreased appetite, weight loss? Yes
Yellow urine? Yes
Cloudy urine? Yes
Tea colored urine? Yes
Are you five years old? Yes
Are you six years old? Yes
Is your favorite color green? Yes
Is your favorite color red? Yes
Can you say any word other than "yes"? Yes

 

[Psai]

I love doing it on pediatrics.

Fevers? Yes
Chills? Yes
Chest pain? Yes
Difficulty breathing? Yes
Headache? Yes
Double vision? Yes
Body aches? Yes
Night sweats? Yes
Diarrhea? Yes
Constipation? Yes
Urinating frequently? Yes
Not urinating at all? Yes
Vomiting? Yes
Increased appetite, weight gain? Yes
Decreased appetite, weight loss? Yes
Yellow urine? Yes
Cloudy urine? Yes
Tea colored urine? Yes
Are you five years old? Yes
Are you six years old? Yes
Is your favorite color green? Yes
Is your favorite color red? Yes
Can you say any word other than "yes"? Yes

Do you lack fevers?
Say it quick so that lack sounds like have

 

[Mass Effect]

One of the funniest suggestions I saw on SDN or reddit was to include psych ROS with medical ROS:

"Any fevers, chills, nausea, vomiting, or hallucinations?"
"Any chest pain, shortness of breath, diarrhea, constipation, or thinking that the radio or television are speaking directly to you?"

Turn pan-positive (medical) patient into pan-negative.

Until they say "yes" and then you've got a whole new problem on your hands.

 

[siliso]

If someone says Yes to Does your hair hurt, it’s time to call it quits and document “Unable to obtain due to clinical condition/mental status”. Bills as high as comprehensive ros.

 

[hamstergang]

In the outpatient world, I find a semi-thorough ROS useful when I'm about to start a new medication. That way, when the patient has some odd complaint at the follow up and blames my medication, I can show they were experiencing that complaint before the med started.

It still doesn't take me long, but I think it also helps that I'm not viewing it as some chore to get through, but instead some useful tool to me.

 

[DoctwoB]

Memorize these beautiful words.

“All other ROS negative except as in hpi”

In all seriousness, though I ask a patient at the end of my history taking something on the order of “any other new symptoms that we haven’t discussed” or something like that. If it’s not important enough for the patient to bring up without specific prompting and it’s not one of the questions I use as part of my hpi focused on the patients chief complaint then it’s not important. For your OSCE though, be a robot.

 

[FlowRate]

Until they say "yes" and then you've got a whole new problem on your hands.

Judging by most teams in our hospital, that problem is now psychiatry's problem.

 

[xClashx]

For CS, if someone comes with right knee pain only, do we do a physical exam on both knees or just one knee?

 

[Psai]

For CS, if someone comes with right knee pain only, do we do a physical exam on both knees or just one knee?

If someone comes in with a pinky lac would you do a thorough exam on all their fingers and toes?

 

[Phiona]

For CS, if someone comes with right knee pain only, do we do a physical exam on both knees or just one knee?

I'm just a lowly pre-med so I can't give advice on CS... but I often see both knees being examined to compare. So if they have some sort of positive finding, it can be compared to the other side to help determine the significance and (potentially) affect their management. Back to my hole now...