Review of systems

A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests.^[1]

Examples

Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. Different sources describe slightly different systems of organizing the organ systems. However, the following are examples of what can be included:

There are 14 systems recognized by the Centers for Medicare and Medicaid Services:^[2]

System	Examples
Constitutional symptoms	unexplained weight loss, night sweats, fatigue/malaise/lethargy, sleeping pattern, appetite, fever, itch/rash, recent trauma, lumps/bumps/masses, unexplained falls
Eyes	visual changes, headache, eye pain, double vision, scotomas (blind spots), floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs amaurosis fugax)
Ears, nose, mouth, and throat (ENT)	Runny nose, frequent nose bleeds (epistaxis), sinus pain, stuffy ears, ear pain, ringing in ears (tinnitus), gingival bleeding, toothache, sore throat, pain with swallowing (odynophagia)
Cardiovascular	chest pain, shortness of breath, exercise intolerance, PND, orthopnoea, oedema, palpitations, faintness, loss of consciousness, claudication
Respiratory	cough, sputum, wheeze, haemoptysis, shortness of breath, exercise intolerance
Gastrointestinal	abdominal pain, unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion, bloating, cramping, anorexia, food avoidance, nausea/vomiting, diarrhea/constipation, inability to pass gas (obstipation), vomiting blood (haematemesis), bright red blood per rectum (BRBPR, hematochezia), foul smelling dark black tarry stools (melaena), dry heaves of the bowels (tenesmus)
Genitourinary	Urinary: Irritative vs Obstructive symptoms: Micturition - incontinence, dysuria, haematuria, nocturia, polyuria, hesitancy, terminal dribbling, decreased force of stream Genital: Vaginal – discharge, pain, Menses - frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus, menarche, menopause, contraception (if relevant), date of last smear test and result
Musculoskeletal	pain, misalignment, stiffness (morning vs day long; improves/worsens with activity), joint swelling, decreased range of motion, crepitus, functional deficit, arthritis
Integumentary/Breast	pruritus, rashes, stria, lesions, wounds, incisions, acanthosis nigricans, nodules, tumors, eczema, excessive dryness and/or discoloration. Breast pain, soreness, lumps, or discharge.
Neurological	Special senses - any changes in sight, smell, hearing and taste, seizures, faints, fits, funny turns, headache, pins and needles (paraesthesiae) or numbness, limb weakness, poor balance, speech problems, sphincter disturbance, higher mental function and psychiatric symptoms
Psychiatric	depression, sleep patterns, anxiety, difficulty concentrating, body image, work and school performance, paranoia, anhedonia, lack of energy, episodes of mania, episodic change in personality, expansive personality, sexual or financial binges
Endocrine	Hyperthyroid: prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite, tremor, palpitations, visual disturbances; Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation, dry skin Diabetes: polydipsia, polyuria, polyphagia (constant hunger without weight gain is more typical for a type I diabetic than type II), symptoms of hypoglycemia such as dizziness, sweating, headache,hunger, tongue dysarticulation Adrenal: difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed places Reproductive (female): menarche, cycle duration and frequency, vaginal bleeding irregularities, use of birth control pills, changes in sexual arousal or libido Reproductive (male): difficulty with erection or sexual arousal, depression, lack of stamina/energy
Hematologic/lymphatic	anemia, purpura, petechia, results from routine hemolytic diseases screening, prolonged or excessive bleeding after dental extraction / injury, use of anticoagulant and antiplatelet drugs (including aspirin), family history of hemophilia, history of a blood transfusion, refused for blood donation
Allergic/immunologic	"Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.

The questions may be asked of the patient in a "head to toe" manner.^[3]

Relationship to history

CMS required history elements^[2]

Type of history	CC	HPI	ROS	Past, family, and/or social
Problem focused	Required	Brief	N/A	N/A
Expanded problem focused	Required	Brief	Problem pertinent	N/A
Detailed	Required	Extended	Extended	Pertinent
Comprehensive	Required	Extended	Complete	Complete

For CMS, a "problem pertinent" ROS is limited to the problem(s) identified in the HPI; an "extended" ROS covers an additional 2 to 9 systems, and a "complete" ROS covers at least 10 additional systems.^[2]

References

1. Tuite PJ, Krawczewski K (April 2007). "Parkinsonism: a review-of-systems approach to diagnosis". Semin Neurol 27 (2): 113–22. doi:10.1055/s-2007-971174. PMID 17390256.
2. "www.cms.gov" (PDF). Retrieved 2011-02-27.
3. Lynn S. Bickley; Peter G. Szilagyi (1 December 2008). Bates' guide to physical examination and history taking. Lippincott Williams & Wilkins. pp. 10–. ISBN 978-0-7817-8058-2. Retrieved 27 February 2011.