A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students and other health care professionals
|Introduction||Breast Exam||Write Ups|
|History of Present Illness||Male Genital/Rectal Exam||The Oral Presentation|
|The Rest of the History||The Upper Extremities||Outpatient Clinics|
|Review of Systems||The Lower Extremities||Inpatient Medicine|
|Vital Signs||Musculo-Skeletal Exam||Clinical Decision Making|
|The Eye Exam||The Mental Status Exam||Physical Exam Lecture Series|
|Head and Neck Exam||The Neurological Exam||A Few Thoughts|
|The Lung Exam||Putting It All Together||Commonly Used Abbreviations|
|Cardiovascular Exam||Medical Links||References|
|Exam of the Abdomen|
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease. It can be applied in several ways:
So, what's the best way to use the ROS? I have always been dubious of its utility as a broadly applied screening tool. Using it in this fashion makes sense if the following hold true:
Unfortunately, aside from a few very specific screening tools (e.g. perhaps depression), there is little evidence to support these assumptions. In fact, positive responses to a screening ROS are often of unclear significance, and may even create problems by generating a wave of additional questions (and testing) that can be of low yield. For these reasons, many clinicians (myself included) favor a more targeted/thoughtful application of ROS questions, based on patient specific characteristics (e.g. age, sex) and risk factors (e.g. history of diabetes → vascular ROS). This strategy, I think, is both more efficient and revealing. As you gain experience, you can make an informed decision about how you'd like to incorporate the ROS into your overall patient care strategy.
It's important to realize that historical Q&A is just one piece of the clinical puzzle. Patient's responses must be interpreted within the context of the rest of their profile, including: risk factors, past history, and exam findings. For example, a patient whose ROS is positive for chest pain, would then be asked to define the dimensions of this symptom including: duration, precipitating events, severity, characterization, radiation, associated symptoms, etc (or questioning using OLD CARTS mnemonics). In addition, an assessment of cardiac risk factors and an organized search for exam findings indicative of vascular disease (e.g. elevated BP, diminished peripheral pulses, audible bruits, etc) would be very relevant. On the basis of the sum of this data, the clinician can come to an informed conclusion about the importance/cause of this patient's chest pain (e.g. angina, heartburn, pulmonary embolism, etc), and use it to guide their subsequent decision making.
Guide To Using This ROS
There is no ROS gold standard. The breadth of questions included is somewhat arbitrary, based on the author's sense of the most commonly occurring illnesses and their symptoms. There is planned redundancy, as the same symptoms often apply to multiple organ systems. Feel free to edit/adapt to fit your clinical needs. Realize that exotic or regional illnesses might require other ROS questions. In addition, some sub-specialty areas use an expanded ROS, specific to the conditions that they evaluate and treat.
I've added a few novel features, designed to clarify why an ROS question is asked and in what direction the response should lead. These include:
I would like to highlight several important limitations:
Clicking on the main categories reveals a list of broad questions. Clicking on any of these symptoms questions reveals a list of common disorders that might be at the root cause of the particular symptom.
More Info About General Symptoms: National Library of Medicine/Medline Plus
More Info About Eye Disorders: NIH National Eye Institute
More Info About Head and Neck Disorders: National Library of Medicine/Medline Plus
More Info About Pulmonary Disorders: National Heart, Lung and Blood Institute
More Info About Cardiovascular Disorders: National Heart, Lung and Blood Institute
More Info About Gastrointestinal Disorders: National Digestive Diseases Clearinghouse
More Info About GU and Renal Disorders: National Kidney and Urologic Diseases Clearinghouse
More Info About Ob/Gyn/Breast Disorders: National Library of Medicine/Medline Plus
More Info About Neurologic Disorders: National Institute of Neurological Disorders and Stroke
More Info About Endocrine Disorders: National Endocrine and Metabolic Diseases Clearinghouse
More Info About Infectious Diseases: National Institute for Allergy and Infectious Diseases and Centers for Disease Control
More Info About Musculoskeletal Disorders: National Institute of Arthritis and Musculoskeletal and Skin Disorders
More Info About Mental Health: National Institute of Mental Health
More Info About Skin Disorders: National Institute of Arthritis and Musculoskeletal and Skin Disorders
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