What should be included in a basic Review of Systems (ROS)?

Basic Review of Systems (ROS)

A comprehensive Review of Systems (ROS) should include assessment of all major body systems to identify symptoms that may indicate underlying medical conditions affecting patient morbidity, mortality, and quality of life.

General Components of a Basic ROS

A basic Review of Systems should systematically cover the following areas:

General

• Fever, night sweats, weight loss/gain, fatigue, changes in body habitus 1

Skin

• Skin discoloration, rash, ulcers, lesions 1

Head, Eyes, Ears, Nose, and Throat (HEENT)

• Eyes: Vision changes or loss, eye pain 1
• Ears: Hearing changes, tinnitus, vertigo 1
• Mouth/Throat: Gum disease, oral ulcers, lesions, pain, difficulty swallowing 1

Lymphatic

• Localized or generalized lymph node enlargement 1

Cardiovascular

• Chest pain, shortness of breath, palpitations, orthopnea, peripheral edema 1
• For patients at risk of peripheral artery disease: walking impairment, claudication, ischemic rest pain 1

Respiratory

• Cough, wheezing, dyspnea, hemoptysis 1

Gastrointestinal

• Nausea, vomiting, diarrhea, constipation, abdominal pain 1
• For patients over 50: postprandial abdominal pain associated with eating and weight loss 1

Genitourinary

• Dysuria, urinary frequency/urgency, hematuria, urethral or vaginal discharge or lesions 1
• For women: menstrual history 1

Endocrine

• Symptoms of hyperglycemia, thyroid disease, hypogonadism 1

Neurological and Psychiatric

• Headaches, memory loss, concentration difficulties, depression, anxiety, mood changes 1
• Paresthesias, numbness, weakness, dizziness, seizures, sleep disorders 1

Musculoskeletal

• Joint pain, swelling, stiffness, muscle weakness 1
• For patients at risk of vascular disease: assessment of walking impairment 1

Special Considerations for Specific Patient Populations

Vascular Assessment

For patients at risk for peripheral artery disease (age >50 with diabetes/smoking, age >70, or known atherosclerosis), include:

• Walking impairment or claudication
• Ischemic rest pain
• Nonhealing wounds of lower extremities 1

Ophthalmologic Assessment

For patients with eye complaints, include:

• Vision changes, eye pain, redness
• Tear production issues (dry eyes)
• Eyelid problems 1

HIV-Infected Patients

Additional focus on:

• Oral thrush or ulceration
• Swallowing difficulties
• Skin rashes or lesions
• Neurological changes 1

Clinical Value and Implementation

The ROS has a case-finding yield of approximately 10.5%, making it a valuable screening tool in clinical practice 2. While the positive predictive value of individual questions may be low (approximately 3.3%), the overall utility in identifying potential health issues is significant 2.

Pitfalls and Caveats

• Avoid using an excessively long ROS that may lead to patient fatigue and decreased accuracy 2
• Be aware that patients with somatization tend to have higher positive responses on ROS (median of 11 vs. 6 for those with objective findings) 3
• Patients with psychiatric comorbidities typically report more positive findings on ROS 3
• The ROS should be tailored based on the patient's presenting complaint and risk factors, but always include the core systems 1

Documentation Requirements

The ROS should be thoroughly documented in the patient's medical record, with particular attention to positive findings that may require further evaluation or treatment 1. This documentation is essential for comprehensive patient care and appropriate medical decision-making.