What exactly should you ask when doing a review of systems?

[Long Dong]

Yes I'm totally clueless about this when I go to my precepter and do an HnP on a patient. Some of my classmates tell me different things about what exactly goes in the review of systems, can you guys tell me what exactly do you ask so I can get different oppinions on what should go in there. And if you have a mnemonic that would be great. Thanks ahead of time.

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[Flobber]

Yes I'm totally clueless about this when I go to my precepter and do an HnP on a patient. Some of my classmates tell me different things about what exactly goes in the review of systems, can you guys tell me what exactly do you ask so I can get different oppinions on what should go in there. And if you have a mnemonic that would be great. Thanks ahead of time.

We just went over this in our Clin Med course. The doc who talked to our group about it said to basically go from head to toe, running over any abnormalities in the various systems (e.g. CNS, ENT, heart, lungs, GI, etc). You just basically want to find if there are any associated symptoms that you might miss when focusing on the CC.

 

[babyruth]

We were taught that this "is a detailed review of possible complaints in each of the body's systems, looking for complementary or seemingly unrelated symptoms that may or may not have surfaced during the rest of the H&P." (Mosby's)

I usually approach it as asking about other diseases/symptoms that the person might have a history of that corresponds to their complaint. Example: if they came in with dysuria, frequency/urgency, etc. I might ask about STDs, and various other questions about GU, trauma (which is a big catch all question), headaches and fatigue, abdominal pain or problems, history of menstration/pregnancy, etc. etc. We usually are told to ask about 5 things (in order to get enough points).

Does your school do simulated or practice patients?

A third or fourth year might be better able to tell you the condensed (focused) or abbreviated version that is sometimes expected of you during rotations... alas, I am only MSII.

 

[beriberi]

Here's mine:

You been sick recently with anything? cold/cough/flu?
You eating okay?
You going to the bathroom okay?
Anything else bothering you?

And if I am going to get detailed:
You short of breath or your chest hurt?
Anything hurting you?
Fever or chills?
Any discharge anywhere?

Though I do ask as much as I can about the system involved with the cheif complaint.

 

[Dr.Evil1]

Head to toe is probably the best way to approach this:

General: Fever/chills, headache, dizziness
Vision changes, eye pain, eye discharge
Hearing acuity, ear pain, ear discharge
Mouth pain or sores (complete=when was the last time you went to the dentist but my GF is a dentist so I ask this just for her)
Neck: heat/cold intolerence
Chest: Cough, Dyspnea, Wheezes
Heart: Chest pain, SOB on exertion, palp
Abd: Nausea/Vomiting, abd pain, stool changes=diarrhea/dark stools
Gyn: Pelvic pain, ask about STDs if not covered in sexual history, discharge, lots of questions available here
GU: frequency, urgency, incontinence
MS: weakness, joint pain
Neuro: Numbness, tingling, back pain
Psych: You would be surprised how much this is positive. Ask about stress levels or sleep disturbances. Both are a good way to broach depression.
Skin: Rashes, sores

I don't ask about this on all of my patients especially if I think I know what is going on or the patient has a specific organ system complaint. I also occasionally ask more if I have no idea what is going on. What the other poster said about a focused ROS is acutally called associated symptoms which should be part of your HPI. Usually when I see a patient I will tailor my ROS to areas that are appropriate to the pts age. I usually always ask about the lungs, heart and abdomen. I know that it looks like alot to remember but it is really easy if you just look at the paient from head to toe and go down the line. When I was a 3rd year I used to carry a little plastic card with me that had a ROS on it. My ROS is by no means perfect but this is just off the top of my head.

 

[roja]

As a medical student, doing a IM H&P, you should always err on the 'to much information'.

A good guide is Maxwells pocket handbook. It has a good ROS. Also lets you get familiar with lab notations and normals.

 

[BUmmedic]

I finished my 3rd-year last May and have been taking time off to complete a MPH degree program, but I agree with Roja in that you should always err on the side of caution as a medical student. To do a complete ROS, however, would take forever. Look in any good history and physical examination book and see the list that they dedicate to ROS. Impossible.

Mine went from head to toe and sounded a little like this. Mr/Ms. XXX, have you been recently experiencing any...

HA/dizziness
Visual/hearing changes
Taste/smell disturbances
Difficulty speaking/swallowing
Cough/sneeze/congestion/SOB (resting or exertion)
CP/palpitations
N/V/abd pain
Diet/eating habit changes
Bowel and/or stool blood/difficulty/changes
Pain/burning with urination and any frequency/urgency/incontinence
Changes in sexual function/drive
STD and/or pregnancy questions
Muscle/joint aches/pain
Numbness/tingling/weakness of any part of the body
Rashes or other skin/hair changes
Recent weight gain/loss, heat/cold intolerance, sleeping disturbances
... last but not least... a good open-ended question... Is there anything else that is bothering you that you would like to discuss or that you would like to have examined?

As Dr. Evil1 said, you'd be surprised how much of this is positive. Most of it is just passing annoyances, but you never want to miss a red flag or a collection of positives that may indicate an underlying syndrome (such as cold intolerance, recent weight gain, and thinning hair possibly indicating a thyroid abnormality).

Hope this helps...

 

[daria]

For what it's worth; on the advice of my clinical med preceptor ("yes, it's absurd to think of doing in most other contexts, but as a weenie 3rd year in the hospital you should ASK ALL THESE QUESTIONS")... I copied the EXHAUSTIVE LIST of RoS questions from the Schwarz physical exam book onto a cheat sheet. Pasted in below.

Have at it. And inquiring minds want to know... who on earth asks about exposure to diethylstilbestrol?!? Wow...



REVIEW OF SYSTEMS
• General/Constitutional
o Fevers?
o Chills?
o Sweats?
o Weight changes?
o Weakness?
o Fatigue?
o Heat/cold intolerance?
o Bleeding?
o Blood transfusions/possible reactions?
• Skin/Breast
o Rashes?
o Itching?
o Hives?
o Easy bruising?
o Eczema?
o Dryness?
o Changes in skin/hair/nails?
• Head
o “dizziness”
o Headaches
o Pain
o Fainting
o History of head injury
• Eyes
o Use of glasses/contacts
o Current vision
o Change in vision
o Double vision
o Excessive tearing
o Pain
o Recent eye exams?
o Pain when looking at light
o Unusual sensations
o Redness
o Discharge
o Infections
o History of glaucoma
o Cataracts
o Injuries
• Ears
o Hearing difficulty
o Use of hearing aid
o Discharge
o Pain
o Ringing in ears
o Infections
• Nose
o Nosebleeds
o Infections
o Discharge
o Frequency of colds
o Nasal obstruction
o History of injury
o Sinus infections
o Hay fever
• Mouth/Throat
o Condition of teeth
o Last dental appt.
o Condition of gums
o Bleeding gums
o Frequent sore throats
o Burning of tongue
o Hoarseness
o Voice changes
o Pastnasal drip
• Neck
o Lumps
o Goiter
o Pain on mvmt
o Tenderness
o History of “swollen glands”
o Thyroid trouble
• Chest
o Cough
o Pain
o Shortness of breath
o Sputum (quantity, appearance)
o Tuberculosis
o Asthma
o Pleurisy
o Bronchitis
o Coughing up blood
o Wheezing
o Last x-ray
o Last TB test
o Bacille Calmette-Guerin vaccination
• Cardiac
o Chest pain
o High blood pressure
o Palpitations
o Shortness of breath with exertion
o Shortness of breath when lying flat
o Sudden shortness of breath
o While sleeping?
o History of hear attack
o Rheumatic fever?
o Heart murmur?
o Last EKG?
• Vascular
o Pain in hips, legs, calves, thigh while walking
o Swelling of legs
o Varicose veins
o Thrombophlebitis
o Coolness of extremity
o Loss of hair on legs
o Discoloration of extremity
o Ulcers
• Breasts
o Lumps
o Discharge
o Pain
o Tenderness
o Self-exam
• GI
o Appetite
o Excessive hunger
o Excessive thirst
o Nausea
o Swallowing
o Constipation
o Diarrhea
o Heartburn
o Vomiting
o Abdominal pain
o Change in stool color
o Change in stool caliber
o Change in stool consistency
o Frequency of bowel movements
o Vomiting blood
o Rectal bleeding
o Black, tarry stools
o Laxative or antacid use
o Excessive belching
o Food intolerance
o Change in abdominal size
o Hemorrhoids
o Infections
o Jaundice
o Rectal pain
o Previous abdominal x-rays
o Hepatitis
o Liver disease
o Gallbladder disease
• Urinary
o Frequency
o Urgency
o Difficulty in starting stream
o Incontinence
o Excessive urination
o Pain on urination
o Burning
o Blood in urine
o Infections
o Stones
o Bed-wetting
o Flank pain
o Awakining at night to urinate
o History of retention
o Urine color
o Urine odor
• Male genitalia
o Lesions on penis
o Discharge
o Impotence
o Pain
o Scrotal masses
o Hernias
o Frequency of intercourse
o Ability to enjoy sexual relations
o Fertility problems
o Prostate problems
o History of VD and treatment
• Female genitalia
o Lesions on external genitalia
o itching
o discharge
o last pap smear and result
o pain on intercourse
o frequency of intercourse
o birth control methods
o ability to enjoy sex
o fertility problems
o hernias
o history of VD
o history of diethylstilbestrol exposure
o age at menarche
o interval between periods
o duration of periods
o amount of flow
o date of last period
o bleeding between periods
o number of pregnancies
o abortions
o term deliveries
o complications of pregnancies
o description of labor
o number of living children
o menstrual pain
o age at menopause
o menopausal symptoms
o postmenopauseal bleeding
• musculoskeletal
o weakness
o paralysis
o muscle stiffness
o limitation ofmovement
o joint pain
o joint stiffness
o arthritis
o gout
o back problems
o muscle cramps
o deformities
• neurologic
o fainting
o dizziness
o blackouts
o paralysis
o strokes
o numbness
o tingling
o burning
o tremors
o loss of memory
o psychiatric disorders
o mood changes
o nervousness
o speech disorders
o unsteadiness of gait
o general behavioral change
o loss of consciousness
o hallucinations
o disorientation

 

[shocker]

Holy ****. How could you connect with your patient as you asked the 250 questions, which you would have to read off a cheat sheet. I know we need to be thorough but that is overkill. Our clinical class told us to ask approx. 3-4 things from each section (HEENT, skin, pulm., etc).

Example for skin:

Any rashes?
Any dry spots?
Any discolorations?

Also, we were told to never combine problems because people may just answer one of them.

Any coughing, wheezing?

I think you could get away with it sometimes though.

 

[erin682]

You need to be clear with what your preceptor expects of you in a review of systems. Sometimes they are gonna be straightforward and admit that a complete review of systems like the one posted already is bull and that you would never really do anything like that. Others are sticklers and expect you to follow the book exactly to the letter.

I asked my preceptor what he expected and I have to do the whole list. It blows but if thats what you're being graded on then you have to do it.

Holy ****. How could you connect with your patient as you asked the 250 questions, which you would have to read off a cheat sheet. I know we need to be thorough but that is overkill.

I totally agree with that. My first patient was almost deaf and I had to sit there and yell have you had and penile discharge when he came in for chest pain and jaundice. My face must have been bright red. It sucked.

 

[Hosehead]

Constitutional: General health, energy, sleep, appetite, fevers, chills, sweats, weight.

Skin: Pruritus, sores, pigmentary changes, bruising, hair, nails, change in mole, new moles.

Head: Trauma, headaches, dizziness, syncope.

Eyes: Visual problems, blindness, blurring, inflammation, spots, flashes.

Ears: Deafness, otalgia, tinnitus.

Nose: Rhinitis, epistaxis, sinusitis.

Mouth and Throat: Dental problems, dentures, sores, hoarseness, dysphagia.
Neck Pain

Lymph Nodes: Swelling

Breasts: Mass, tenderness, discharge.

Respiratory Exercise tolerance, dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, pleurisy

Cardiovascular: Palpitations, pain: chest/arm/jaw pain or pressure with exertion, paroxysmal nocturnal dyspnea (PND), dyspnea, orthopnea, edema, syncope.

Gastrointestinal Tract Pain, indigestion, heartburn, nausea, vomiting, diarrhea, constipation, change in bowels, melena, rectal problems or bleeding, jaundice.

Urinary Tract Dysuria, nocturia, pyuria hematuria, urgency, incontinence.

Female Genitalia: Vaginitis, sores, venereal disease, menarche, menses, dysmenorrhea, metrorrhagia, premenstrual syndrome, menopause, not flashes, sexual dysfunction, bleeding after intercourse.

Male Genitalia: Sores, discharge, scrotal pain, hernia, sexual dysfunction.

Joints and Extremities: Cramps, varicosities, phlebitis, edema, arthralgias, arthritis, low back pain.

Endocrine: Heat or cold intolerance, polydipsia, polyuria, polyphagia.

Central Nervous System: Diplopia, dysphasia, dysphagia, paralysis, paresthesia, clumsiness, balance, gait,
System: involuntary movements, tremor, seizures, dizziness, syncope, headaches, memory, depression, anxiety.


I know it seems like a lot but it isn't too bad once you memorize it. ROS is a very good thing to know for year 3 and 4.