What is the approach to a focused review of systems (ROS)?

Approach to a Focused Review of Systems (ROS)

A focused review of systems (ROS) should be systematically targeted to relevant organ systems based on the patient's chief complaint, with specific questions aimed at uncovering related symptoms that may not be readily apparent in the initial presentation.

Purpose and Definition

A focused ROS is a targeted inquiry into specific organ systems that:

• Identifies symptoms related to the chief complaint that the patient may not have volunteered
• Uncovers potential end-organ damage or complications
• Helps differentiate between possible diagnoses
• Guides further diagnostic testing and management

Key Components of an Effective Focused ROS

1. Determine Relevant Systems

• Select organ systems based on:
  • The patient's chief complaint
  • Likely differential diagnoses
  • Known comorbidities that may influence presentation
  • Age and demographic-specific concerns

2. Ask Properly Structured Questions

• Begin with general inquiries rather than confirmatory questions 1, 2
  • General inquiries (e.g., "What can I do for you today?") lead to:
    • Significantly longer problem presentations
    • More discrete symptoms reported
    • Higher patient satisfaction with physician listening
  • Avoid closed-ended requests for confirmation (e.g., "Sore throat, huh?")

3. System-Specific Approach

Based on the chief complaint, focus on the following systems:

Cardiovascular System

• Ask about chest pain, palpitations, dyspnea on exertion, orthopnea, edema
• Particularly important in patients with hypertension to assess for end-organ damage 3

Respiratory System

• Inquire about cough, shortness of breath, wheezing, hemoptysis
• Essential for respiratory complaints or when cardiovascular issues are suspected

Neurological System

• Ask about headaches, dizziness, vision changes, weakness, numbness, confusion
• Critical when evaluating hypertensive patients for potential cerebrovascular complications 3

Gastrointestinal System

• Inquire about abdominal pain, nausea, vomiting, changes in bowel habits
• Important for abdominal complaints, which are often unfocused and may involve multiple organ systems 4

Genitourinary System

• Ask about urinary frequency, urgency, dysuria, hematuria, changes in urine output
• Essential for renal assessment in hypertensive patients 3

Implementation Strategies

1. Use a Systematic Approach

• Develop a standardized but adaptable template for each common chief complaint
• Document both positive and pertinent negative findings
• Consider using the PICO framework to structure your approach 3, 5:
  • Population: Identify patient characteristics relevant to the complaint
  • Intervention/Indicator: Focus on specific symptoms that may indicate diagnosis
  • Comparator: Consider alternative explanations for symptoms
  • Outcome: Determine what symptoms would indicate severity or complications

2. Avoid Common Pitfalls

• Diagnostic overshadowing: Don't attribute new symptoms to pre-existing conditions without proper evaluation 3
• Regression to the mean: Be aware that extreme measurements (like very high blood pressure) often decrease on repeat measurement without intervention 3
• Unfocused complaints: Recognize that certain complaints (back pain, dizziness, abdominal pain) often cross multiple organ systems and require broader ROS 4

3. Documentation Best Practices

• Document both positive and pertinent negative findings
• Note when systems were reviewed and found to be negative
• Avoid using generic statements like "all other systems negative" without specific documentation

Special Considerations

Elderly Patients

• Include cognitive assessment and functional status questions
• Ask about falls, changes in mobility, and medication adherence

Patients with Intellectual Disabilities

• Compare current functioning to historical baseline 3
• Include questions about recent life changes (caregiver changes, living situation changes)
• Consider mood and behavior changes that might indicate underlying medical issues

Acute vs. Chronic Complaints

• For acute complaints: Focus on onset, duration, exacerbating/alleviating factors
• For chronic complaints: Focus on changes from baseline, functional impact, and treatment response

Conclusion

A properly conducted focused ROS improves diagnostic accuracy, enhances patient satisfaction, and optimizes clinical efficiency. By systematically targeting relevant organ systems with appropriate questioning techniques, clinicians can uncover important clinical information that might otherwise be missed.