Can you provide a comprehensive review of systems (ROS) checklist for evaluating a patient?

Comprehensive Review of Systems Checklist

A systematic review of systems should assess symptoms across all major body systems to identify health concerns beyond the chief complaint, with particular attention to constitutional symptoms, organ-specific complaints, and population-specific risk factors. 1

Constitutional/General Symptoms

• Fever, night sweats, unexplained weight loss, and changes in body habitus require assessment as these may indicate serious underlying pathology including infections, malignancies (particularly lymphomas), or metabolic disorders 1, 2
• Document current weight compared to baseline with dietary assessment 1
• Night sweats should be documented with frequency, severity, pattern, and associated symptoms (weight loss, fever, lymphadenopathy), as their presence combined with B symptoms significantly increases concern for serious pathology 2

Skin

• Assess for discoloration, rash, ulcers, lesions, and acanthosis nigricans 1
• Examine insulin injection or insertion sites for lipodystrophy in diabetic patients 3

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

• Visual changes or disturbances warrant evaluation 1
• Assess for oral thrush, ulceration, and swallowing difficulties 1
• Evaluate for localized or generalized lymph node enlargement 1
• Thyroid palpation should be performed 3

Respiratory System

• Inquire about cough, shortness of breath, wheezing, and chest pain 1

Cardiovascular System

• Chest pain, palpitations, orthopnea, and edema require assessment 1
• For patients with cardiovascular concerns, assess volume status, jugular venous pressure, and peripheral edema 1
• Blood pressure determination at every visit, with orthostatic measurements when indicated 3

Gastrointestinal System

• Evaluate nausea, vomiting, abdominal pain, diarrhea, and changes in bowel habits 1
• Liver function assessment should be included in annual evaluations 3

Genitourinary System

• Assess urinary frequency, urgency, and dysuria 1
• For women, obtain menstrual history 1
• Spot urinary albumin-to-creatinine ratio should be checked annually 3

Musculoskeletal System

• Evaluate joint pain, stiffness, swelling, and muscle weakness 1
• Consider bone pain assessment, particularly in at-risk populations 3

Neurological System

• Changes in neurological function or mental status require assessment 1
• For suspected neurological disorders, include timed gait, motor movements, reflexes, and Babinski signs 1
• Cognitive performance assessment should be considered in patients ≥65 years 3

Psychiatric/Behavioral Health

• Screen for depression, anxiety, diabetes distress, fear of hypoglycemia, and disordered eating 3
• Functional performance assessment should be considered in elderly patients 3

Population-Specific Considerations

Diabetic Patients

• Comprehensive foot examination including visual inspection for skin integrity, callous formation, foot deformities, ulcers, and toenail abnormalities 3, 1
• Screen for peripheral arterial disease with pedal pulse assessment (refer for ankle-brachial index if diminished) 3
• Assess temperature, vibration or pinprick sensation, and perform 10-g monofilament examination 3
• Fundoscopic examination with referral to eye specialist 3

Elderly Patients (≥65 years)

• Assessment of functional and cognitive performance 1
• Evaluate frailty, fall risk, and need for assistive devices 3, 1
• Disability assessment including physical, cognitive, vision, and auditory impairments 3

Patients with Suspected Vascular Disease

• For acute limb ischemia concerns, focus on uncovering atrial fibrillation, myocardial infarction, cardiomyopathy, valvular heart disease, aortic disease, and hypercoagulable states 1

Social and Behavioral Assessment

• Eating patterns and weight history 3
• Physical activity and sleep behaviors; screen for obstructive sleep apnea 3
• Tobacco, alcohol, and substance use 3
• Assess social determinants of health including food security, housing stability, transportation access, financial security, and community safety 3

Clinical Pitfalls to Avoid

• Do not rely solely on patient's chief complaint—the review of systems identifies symptoms not mentioned initially that may be relevant to diagnosis and treatment 1, 4
• Research demonstrates that review of systems has higher therapeutic yield (7%) compared to many routine laboratory tests, making it a valuable case-finding maneuver 4
• Serious ROS complaints are more likely to be addressed by providers, but most ROS complaints noted are not adequately followed up—ensure documented symptoms receive appropriate evaluation 5