Adult Review of Systems (ROS)

Overview

The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area. It can be applied in several ways:

  1. As a screening tool asked of every patient that the clinician encounters.
  2. Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to uncover occult disease of the prostate to men over 50; or using a cardiovascular ROS in patients who have cardiovascular risk factors).

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:

  1. The questions asked reflect an array of common and important clinical conditions
  2. These disorders would go unrecognized if the patient was not specifically prompted
  3. The identification of these conditions then has a positive impact on morbidity/mortality

Unfortunately, aside from a few specific screening tools (e.g. 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 → perform cardiovascular 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 recognize that positive responses will require follow-up questioning. For example, if a patient responds “yes” to an ROS question about chest pain, you would then need to ask additional questions to further define the core dimensions of this symptom. The OLD CARTS mnemonic (or other similar frameworks) provide structure for these follow-up questions. In addition, for a patient with chest pain, an assessment of cardiac risk factors and an organized search for exam findings indicative of vascular disease (e.g. elevated BP, diminished peripheral pulses, etc.) would be relevant. In addition to also consider non-cardiac etiologies (e.g. pulmonary, GI, MSK, etc.). 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), and use this 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:

  1. Clicking on the main questions reveals a list of common disorders that might be at the root cause of the particular symptom.
  2. Comments in parentheses that follow include other symptoms and/or historical features commonly linked to that particular disorder.
  3. "Red flag" indicates symptoms that are particularly worrisome for a serious illness.
  4. Where possible, I've bundled the diagnostic possibilities into clinically logical groupings (e.g. acute/chronic, painful/painless, upper/lower, etc.).

I would like to highlight several important limitations:

  1. The list of possible diagnoses that follows a question is not exhaustive. In addition please realize that no patient responses are pathognomonic.
  2. Common associated symptoms, risk factors, exam findings, and selected links to additional info are provided in (parentheses) after most items on the differential. This is only meant to point you in the right direction in terms of possible diagnoses – it is not meant to be inclusive.
  3. The disease categorizations reflect rough groupings. There are many exceptions. For example, disorders listed in the "acute" section may have chronic presentations, those described as "upper abdominal" may present w/thoracic symptoms, etc.

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.

General
Vision
Head and Neck (H&N)
Pulmonary
Cardiovascular (C/V)
Gastrointestinal
Genito-Urinary
Hematology/Oncology
Ob/Gyn/Breast
Neurological
Endocrine
Infectious Diseases
Musculoskeletal
Mental Health
Skin and Hair

Finally, we’ve developed the on-line Web App Digital DDx, which provides a much more extensive diagnostic support tool. ROS questions are provided, along with a clickable tree of diagnoses to aid in the interpretation of responses. It also contains many other features that highlight the connections between organ based symptoms and specific disorders.