What review-of-systems (ROS) questions should be asked for an existing outpatient clinic patient presenting with a painful rash on the left side of the chest?

Review of Systems Questions for Painful Rash on Left Chest

For a patient presenting with a painful rash on the left side of the chest, your ROS should prioritize identifying herpes zoster (shingles) and ruling out life-threatening conditions, particularly cardiac causes that can mimic or coexist with dermatologic presentations.

Critical Systems to Address

General Constitutional Symptoms

• Have you had any fever or chills? (Essential for identifying systemic infection or sepsis)
• Have you felt more fatigued than usual? (May indicate systemic illness or post-herpetic complications)
• Have you had any unexplained weight loss? (Red flag for malignancy or systemic disease)

Skin (Primary Focus)

• When did the rash first appear, and how has it changed? (Herpes zoster typically progresses from pain to vesicular eruption over 24-48 hours)
• Did you have pain, burning, or tingling in this area BEFORE the rash appeared? (Prodromal symptoms are classic for zoster)
• Does the rash cross the midline of your body? (Zoster typically respects dermatomal boundaries and does not cross midline)
• Have you had chickenpox or shingles before? (Risk factor assessment)
• Are there any blisters or fluid-filled lesions? (Vesicular pattern confirms zoster)

HEENT (Critical for Complications)

• Have you had any headaches? (Meningitis complication of disseminated zoster)
• Have you had any eye pain, redness, or blurry vision? (Herpes zoster ophthalmicus is a medical emergency requiring immediate ophthalmology referral)
• Have you noticed any sores or rash on your face, mouth, or near your ears? (Identifies cranial nerve involvement or Ramsay Hunt syndrome)
• Have you had any nasal discharge? (Less critical but completes cranial assessment)

Cardiovascular (MUST Rule Out Cardiac Causes)

The 2021 AHA/ACC Chest Pain Guidelines emphasize that chest pain evaluation must always consider cardiac causes first 1. Even with visible rash, cardiac pathology can coexist or be the primary problem.

• Do you have any chest pressure, tightness, or squeezing sensation separate from the rash pain? (Anginal symptoms may be masked by dermatologic pain)
• Does the pain worsen with exertion or emotional stress? (Cardiac ischemia typically has these triggers) 1
• Have you had any palpitations or irregular heartbeats? (Associated cardiac symptoms)
• Does the pain radiate to your jaw, neck, left arm, or between your shoulder blades? (Classic anginal radiation patterns) 1
• Have you had any lightheadedness, dizziness, or near-fainting episodes? (Cardiac compromise indicators)

Respiratory

• Have you had any shortness of breath? (May indicate cardiac cause, pulmonary embolism, or pneumonia—all can present with chest pain) 2
• Have you had any cough? (Pneumonia or other pulmonary pathology)
• Does the pain worsen when you take a deep breath? (Pleuritic pain suggests pulmonary or musculoskeletal cause rather than zoster)

Neurological (Embedded in Other Systems but Critical)

• Have you had any weakness, numbness, or tingling anywhere in your body? (Neurologic complications of zoster or alternative diagnoses)
• Have you had any confusion or difficulty thinking clearly? (Encephalitis or systemic illness)

Gastrointestinal

• Have you had any nausea or vomiting? (Can accompany severe pain, cardiac ischemia, or systemic illness) 1
• Have you had any abdominal pain? (Thoracic zoster can involve abdominal dermatomes; also cardiac equivalent symptom)

Endocrine

• Have you noticed increased thirst or urination? (Diabetes is a risk factor for zoster and affects healing)
• Any sensitivity to heat or cold? (Thyroid dysfunction can affect immune response)
• Any recent unexplained changes in your weight? (Immunocompromise or malignancy screening)

Immunologic/Infectious Disease History (Add These)

• Do you have any conditions that affect your immune system (HIV, cancer, organ transplant)? (Major risk factor for severe or disseminated zoster)
• Are you taking any medications that suppress your immune system (steroids, chemotherapy, biologics)? (Critical for risk stratification)
• Have you been around anyone with chickenpox or shingles recently? (Exposure history)

OB/GYN (As Listed)

• Are you sexually active? (HIV risk assessment)
• Are you taking birth control? (Medication interactions if antivirals needed)
• Could you be pregnant? (Affects treatment options and urgency)

Clinical Reasoning

The 2021 AHA/ACC guidelines mandate that chest pain evaluation must first exclude life-threatening cardiac, aortic, and pulmonary causes 1. The presence of a visible rash does NOT eliminate cardiac pathology—approximately 10-34% of chest pain presentations have cardiac causes 2, and the physical examination "contributes almost nothing in diagnosing a heart attack" 2.

Key pitfall to avoid: Do not assume visible dermatologic findings explain all symptoms. Women and diabetic patients may present with atypical cardiac symptoms that could be misattributed to zoster pain 1.

The ROS serves dual purposes here: (1) Identifying zoster complications (ophthalmicus, dissemination, neurologic involvement) that require urgent intervention, and (2) ensuring cardiac and other life-threatening causes are not missed 1, 3, 4.