Review of systems

Technique for eliciting medical history

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

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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. Unspecified and other symptoms can't consider for both HPI and ROS:

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

System  | Examples

|

Constitutional symptoms | weight loss, day sweats, fatigue/malaise/lethargy, sleeping pattern, appetite, fever, itch/rash, recent trauma, lumps/bumps/masses
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, loss of appetite, 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, cognitive 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

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CMS required history elements[4] 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. The chances of double dipping should be avoided while taking ROS from History. There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them.[4]

> This established patient has had a fever with sore/scratchy throat and severe headache for the past three days. He has had a little nausea but no vomiting. He said his pain is relieved with cold drinks and ibuprofen.

In the above example if you take throat as location in HPI, you can not take sore/scratchy throat in ROS as ENT element. Most of the double dipping will happen in ENT section since it is a combined system. Of note, some would say that the statement of "No known allergies" could be calculated as part of the review of systems (ROS). The statement suggests the patient is not allergic to any medications, which is commonly part of the "past medical history" element.[4]

> The patient was brought up by an aunt; Patient having nasal problems for last 4 days, symptoms including runny nose / rhinorrhea. Denies cough, no fever, pneumonia, severe headache for the past three days.

In the above example, if you take Nose as location, you can not take runny nose/rhinorrhea in ROS as an ENT element. Double dipping is against the rules. The common double dipping example (above) uses the elements of HPI (location and associated signs and symptoms) for both the HPI and the ROS. Double dipping may increase revenue by making it possible to qualify for a higher level of history and as such be considered fraud or abuse. There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS. The ROS is a distinct review of systems. For example: if the documentation reads "'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the MSK (musculoskeletal) review of systems." It goes on to explain that if the patient's complaint is followed by "no other MSK issues", then it can be counted in the ROS as well as the HPI.[4]

## References

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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 17390256.113-22&rft.date=2007-04&rft_id=info:doi/10.1055/s-2007-971174&rft_id=info:pmid/17390256&rft.aulast=Tuite&rft.aufirst=PJ&rft.au=Krawczewski,+K&rft_id=http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-971174&rfr_id=info:sid/en.wikipedia.org:Review+of+systems" class="Z3988">
2. ^ "www.cms.gov" (PDF). Archived from the original (PDF) on 2011-03-22. 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.
4. ^ a b c d "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.

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Medical examination and history taking

Medical history|

* Chief complaint
* History of the present illness
* Systems review
* Nursing assessment
* Allergies
* Medications
* Past medical history
* Family history
* Social history
* Psychiatric history
* Progress notes
* Mnemonics
* SAMPLE
* OPQRST
* SOAP
* COASTMAP

Physical examination|

| General/IPPA|

* Inspection
* Auscultation
* Palpation
* Percussion

|

Vital signs|

* Temperature
* Heart rate
* Blood pressure
* Respiratory rate

HEENT|

* Eye examination
* Ophthalmoscopy
* Swinging light test
* Hearing
* Weber
* Rinne

Respiratory|

* Respiratory sounds

Cardiovascular|

* Cardiac examination
* Peripheral vascular examination
* Heart sounds
* Other
* Abdominojugular test
* Ankle–brachial pressure index

Abdominal|

* Liver span
* Rectal examination
* Bowel sounds

Musculoskeletal|

* Knee examination
* Hip examination
* Shoulder examination
* Elbow examination
* GALS screen

Neurological|

* Mental status
* Mini–mental state examination
* Cranial nerve examination
* Upper limb neurological examination

Neonatal|

* Apgar score
* Ballard Maturational Assessment

Gynecological|

* Well-woman examination
* Pap test
* Breast examination

Sports|

* Athletic heart syndrome
* Sudden cardiac death
* RED-S

Assessment and plan|

* Medical diagnosis
* Differential diagnosis

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* e

Signs and symptoms that are general or constitutional

Temperature|

| heat|

* Fever
* of unknown origin
* drug-induced
* postoperative
* Hyperthermia
* Hyperhidrosis
* Night sweats

|

cold|

* Chills
* Hypothermia

Aches and pains|

* Headache
* Chronic pain
* Cancer pain
* Myalgia
* Tenderness

Malaise and fatigue|

* Lassitude
* Lethargy
* Atrophy
* of muscle
* Asthenia

Miscellaneous|

* Cachexia
* Anorexia
* Polyphagia and polydipsia
* Flu-like symptoms

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Signs and symptoms relating to perception, emotion and behaviour

Cognition|

* Confusion
* Delirium
* Psychosis
* Delusion
* Amnesia
* Anterograde amnesia
* Retrograde amnesia
* Convulsion
* Dizziness
* Disequilibrium
* Presyncope/Lightheadedness
* Vertigo

Emotion|

* Anger
* Anxiety
* Depression
* Fear
* Paranoia
* Hostility
* Irritability
* Suicidal ideation

Behavior|

* Verbosity
* Russell's sign

Perception|

* Sensory processing disorder
* Hallucination
* Auditory
* Tactile
* Visual
* Smell
* Anosmia
* Hyposmia
* Dysosmia
* Parosmia
* Phantosmia
* Hyperosmia
* Synesthesia
* Taste
* Ageusia
* Hypogeusia
* Dysgeusia
* Hypergeusia

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Signs and symptoms relating to the circulatory system

Chest pain|

* Referred pain
* Angina
* Levine's sign

Auscultation|

* Heart sounds
* Split S2
* S3
* S4
* Gallop rhythm
* Heart murmur
* Systolic
* Functional murmur
* Still's murmur
* Diastolic
* Pulmonary insufficiency
* Graham Steell murmur
* Continuous
* Carey Coombs murmur
* Mitral insufficiency
* Presystolic murmur
* Pericardial friction rub
* Heart click
* Bruit
* carotid

Pulse|

* Tachycardia
* Bradycardia
* Pulsus paradoxus
* doubled
* Pulsus bisferiens
* Pulsus bigeminus
* Pulsus alternans

Other|

* Palpitations
* Apex beat
* Cœur en sabot
* Jugular venous pressure
* Cannon A waves
* Hyperaemia

Shock|

* Cardiogenic
* Obstructive
* Hypovolemic
* Distributive
* See further Template:Shock

Cardiovascular disease|

| Aortic insufficiency|

* Collapsing pulse
* De Musset's sign
* Duroziez's sign
* Müller's sign
* Austin Flint murmur
* Mayne's sign

|

Other endocardium|

* endocarditis: Roth's spot
* Janeway lesion/Osler's node
* Bracht–Wachter bodies

Pericardium|

* Cardiac tamponade/Pericardial effusion: Beck's triad
* Ewart's sign

Other|

* rheumatic fever:
* Anitschkow cell
* Aschoff body
* EKG
* J wave
* Gallavardin phenomenon

Vascular disease|

| Arterial|

* aortic aneurysm
* Cardarelli's sign
* Oliver's sign
* pulmonary embolism
* Right heart strain
* radial artery sufficiency
* Allen's test
* pseudohypertension
* thrombus
* Lines of Zahn
* Adson's sign
* arteriovenous fistula
* Nicoladoni–Branham sign

|

Venous|

* Friedreich's sign
* Caput medusae
* Kussmaul's sign
* Trendelenburg test
* superior vena cava syndrome
* Pemberton's sign

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Signs and symptoms relating to the respiratory system

Auscultation|

* Stethoscope
* Respiratory sounds
* Stridor
* Wheeze
* Crackles
* Rhonchi
* Stertor
* Squawk
* Pleural friction rub
* Fremitus
* Bronchophony
* Death rattle
* Elicited findings
* Percussion
* Pectoriloquy
* Whispered pectoriloquy
* Egophony

Breathing|

| Rate|

* Apnea
* Prematurity
* Dyspnea
* Hyperventilation
* Hypoventilation
* Hyperpnea
* Tachypnea
* Hypopnea
* Bradypnea

|

Pattern|

* Agonal respiration
* Biot's respiration
* Cheyne–Stokes respiration
* Kussmaul breathing
* Ataxic respiration

Other|

* Respiratory distress
* Respiratory arrest
* Orthopnea/Platypnea
* Trepopnea
* Aerophagia
* Asphyxia
* Breath holding
* Mouth breathing
* Snoring

Other|

* Chest pain
* In children
* Precordial catch syndrome
* Pleurisy
* Nail clubbing
* Cyanosis
* Cough
* Sputum
* Hemoptysis
* Epistaxis
* Silhouette sign
* Post-nasal drip
* Hiccup
* COPD
* Hoover's sign
* asthma
* Curschmann's spirals
* Charcot–Leyden crystals
* chronic bronchitis
* Reid index
* sarcoidosis
* Kveim test
* pulmonary embolism
* Hampton hump
* Westermark sign
* pulmonary edema
* Kerley lines
* Hamman's sign
* Golden S sign

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Signs and symptoms relating to the human digestive system or abdomen

Gastrointestinal
tract|

* Nausea
* Vomiting
* Heartburn
* Aerophagia
* Pica
* Trichophagia
* Pagophagia
* Geophagia
* Dysphagia
* oropharyngeal
* esophageal
* Odynophagia
* Bad breath
* Xerostomia
* Hypersalivation
* Burping

* Goodsall's rule
* Chilaiditi syndrome
* Dance's sign
* Aaron's sign
* Arapov's sign
* Markle's sign
* McBurney's point
* Sherren's triangle

* Radiologic signs: Hampton's line
* Klemm's sign

Accessory|

* liver: Councilman body
* Mallory body

* biliary: Boas' sign
* Courvoisier's law
* Charcot's cholangitis triad/Reynolds' pentad
* cholecystitis (Murphy's sign
* Lépine's sign
* Mirizzi's syndrome)
* Nardi test

Defecation|

* Flatulence
* Fecal incontinence and encopresis
* Fecal urgency
* Fecal occult blood
* Rectal tenesmus
* Constipation
* Obstructed defecation
* Diarrhea
* Rectal discharge

Abdomen|

| Pain|

* Abdominal pain
* Acute abdomen
* Colic
* Baby colic
* Abdominal guarding
* Blumberg's sign

|

Distension|

* Abdominal distension
* Bloating
* Ascites
* Tympany
* Shifting dullness
* Fluid wave test

Masses|

* Abdominal mass
* Hepatosplenomegaly
* Hepatomegaly
* Splenomegaly

Other|

* Jaundice
* Mallet-Guy's sign
* Puddle sign
* Ballance's sign
* Aortic insufficiency
* Castell's sign
* Kehr's sign
* Cullen's sign
* Grey Turner's sign

Hernia|

* Howship–Romberg sign
* Hannington-Kiff sign

Other|

* Psoas sign
* Obturator sign
* Rovsing's sign
* Hamburger sign
* Heel tap sign
* Aure-Rozanova's sign
* Dunphy's sign
* Alder's sign
* Lockwood's sign
* Rosenstein's sign
* Cupola sign
* Fothergill's sign
* Carnett's sign
* Massouh's sign
* Sister Mary Joseph nodule
* Blumer's shelf

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Signs and symptoms relating to skin and subcutaneous tissue

Disturbances of
skin sensation|

* Hypoesthesia
* Paresthesia
* Formication
* Hyperesthesia

* Hypoalgesia
* Hyperalgesia

Circulation|

* Cyanosis
* Pallor
* Livedo
* Livedo reticularis
* Flushing
* Petechia
* Blanching

Edema|

* Peripheral edema
* Anasarca

Other|

* Rash
* Desquamation
* Induration
* Diaphoresis
* Mass
* Neck mass

Skin|

* Asboe-Hansen sign
* Auspitz's sign
* Borsari's sign
* Braverman's sign
* Crowe sign
* Dennie–Morgan fold
* Darier's sign
* Fitzpatrick's sign
* Florid cutaneous papillomatosis

* Gottron's sign
* Hutchinson's sign
* Janeway lesion
* Kerr's sign
* Koebner's phenomenon
* Koplik's spots
* Leser-Trelat sign
* Nikolsky's sign
* Pastia's sign
* Russell's sign
* Wickham striae
* Wolf's isotopic response
* Munro's microabscess

Nails|

* Aldrich-Mees' lines
* Beau's lines
* Muehrcke's lines
* Terry's nails

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* e

Signs and symptoms relating to movement and gait

Gait|

* Gait abnormality
* CNS
* Scissor gait
* Cerebellar ataxia
* Choreic gait
* Festinating gait/Parkinsonian gait
* Magnetic gait
* Marche à petit pas
* Propulsive gait
* Stomping gait
* Spastic gait
* Truncal ataxia
* Vestibular gait
* Muscular
* Myopathic gait/Waddling gait
* Trendelenburg gait
* Pigeon gait
* Foot drop
* Steppage gait
* Toe walking
* Asymmetric gait
* Leaping gait
* Asynchronous gait
* Gunslinger's gait
* Hemiparetic gait
* Limp
* Antalgic gait
* Deformity
* Lotus gait

Coordination|

* Ataxia
* Cerebellar ataxia
* Dysmetria
* Dysdiadochokinesia
* Pronator drift
* Dyssynergia
* Sensory ataxia
* Asterixis
* Abasia
* Hemimotor neglect

Abnormal movement|

* Athetosis
* Chorea
* Tremor
* Fasciculation
* Fibrillation
* Myokymia
* Myoclonus
* Hyperkinesia / Hypokinesia
* Myotonia / Pseudomyotonia
* Hypotonia
* Stereotypy
* Akathisia
* Echopraxia
* Echolalia

Posturing|

* Abnormal posturing
* Stooped posture
* Camptocormia
* Osteoporosis
* Opisthotonus
* Spasm
* Trismus
* Cramp
* Tetany
* Hypertonia
* Joint locking
* Catalepsy
* Waxy flexibility
* Grimacing
* Tonic immobility

Paralysis|

* Flaccid paralysis
* Periodic paralysis
* Spastic paraplegia
* Spastic diplegia
* Spastic paraplegia
* Syndromes
* Monoplegia
* Diplegia / Paraplegia
* Hemiplegia
* Triplegia
* Tetraplegia / Quadruplegia
* General causes
* Upper motor neuron lesion
* Lower motor neuron lesion
* Sleep paralysis

Weakness|

* Hemiparesis
* Gowers' sign
* Locomotive syndrome
* Ptosis

Range of motion|

* Contracture
* Bethlem sign
* Club foot
* Joint stiffness
* Ankylosis
* Hypermobility
* Gorlin sign
* EDS
* HSD
* Boutonniere deformity
* Swan neck deformity
* Scoliosis
* Kyphosis

Other|

* Rachitic rosary
* Flat feet
* Overpronation/Flexible flat feet
* Knock-knee
* Bow-leggedness
* Back knee
* Hyporeflexia
* Hyperreflexia
* Clasp-knife response
* Shivering
* Hypnic jerk
* Astasia-abasia
* Vertigo
* Motion sickness
* Conversion disorder
* Shell shock
* Stupor
* Catatonia
* Dancing mania

* v
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* e

Signs and symptoms relating to the urinary system

Pain|

* Dysuria
* Renal colic
* Costovertebral angle tenderness
* Vesical tenesmus

Control|

* Urinary incontinence
* Enuresis
* Diurnal enuresis
* Giggling
* Nocturnal enuresis
* Post-void dribbling
* Stress
* Urge
* Overflow
* Urinary retention

Volume|

* Oliguria
* Anuria
* Polyuria

Other|

* Lower urinary tract symptoms
* Nocturia
* urgency
* frequency
* Extravasation of urine
* Uremia

Eponymous|

* Addis count
* Brewer infarcts
* Lloyd's sign
* Mathe's sign

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