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. 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).
3. To better define the likely causes of a presenting symptom, as described in the HPI section (e.g. patients w/a chief concern of "chest pain" would be asked detailed cardiac and pulmonary ROS).

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 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 who has chest pain would be asked re: duration, precipitating events, severity, characterization, radiation, associated symptoms, etc. 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. What follows is a much more extensive screening question list then would generally be used. The breadth of questions included is somewhat arbitrary, based on my sense of the most commonly occurring illnesses and their symptoms. There is also some 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 also added a few novel features that clarify why an ROS question is asked and in what direction the response should lead. These include:

1. Clicking on the main questions lists the most common disorders associated with that symptom.
2. Parentheses include symptoms linked to that particular disease.
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 is not meant to be exhaustive. No patient responses are pathognomonic.
2. The symptoms in parentheses represent a partial listing of those most commonly associated w/a particular disorder. They are based on general experience, not discrete evidence.
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.

General

Weight loss?

• lack of access to calories
  • malnutrition, poverty
• lack of interest in calories
  • anorexia, depression, cancer, chronic medical conditions → renal failure, cirrhosis, HIV, TB, etc.
• inability to consume calories
  • mechanical problems
    • stroke (abrupt onset, other focal neurological Sx)
    • esophageal or stomach obstruction
      • cancer (red flags: progressive swallowing problems, wt loss, pain, older)
      • benign stricture
• inability to absorb calories:
  • chronic diarrhea
    • chronic pancreatitis (multiple past episodes pancreatitis, ETOH abuse)
    • celiac disease (chronic)
• elevated metabolic rate
  • malignancy
  • hyperthyroisim (irritability, inability to sleep, diarrhea, palpitations, tremor, heat intolerance)
  • chronic infxn → TB, HIV, etc.

Weight gain?

• decreased metabolic rate
  • inactivity (no regular walking or exercise)
  • hypothyroidism (wt gain, edema, dry skin, constipation, cold intolerance, depression)
• excessive caloric intake
• fluid retention: edema, Sx CHF (C/V RFs, orthopnea, PND, lower extremity edema)

Fatigue?

• sleep disorders
  • obstructive sleep apnea (snoring, obese, observed apnea, poorly rested in AM, daytime fatigue)
• endocrine
  • hypothyroidism (wt gain, edema, dry skin, constipation, cold intolerance, depression)
  • diabetes (poor control, polyuria, polydypsia)
• Heme/Onc
  • Anemia
  • Cancer - type identified based on detailed review major organ systems
• mental health
  • depression
• Musculo-skeletal
  • DJD (chronic pain, difficulty moving)
  • Chronic or sub-acute inflammatory disorders - RA, Lupus, polymyalgia, other
• Infection
  • Chronic: HIV, TB
  • Sub-acute: endocarditis
• Pulmonary
  • COPD (acute or chronic, cough, smoking, wheezing)
  • Other chronic pulmonary disorders
• Cardio/Vascular
  • CHF (C/V RFs, orthopnea, PND, lower extremity edema)
  • Bradycardia (fatigue, decrease exercise tolerance, CHF Sx)
• Neuro
  • Disorders assoc w/difficulty moving
    • Neuromuscular disease (progressive, muscle weakness)
    • Stroke
    • Parkinson's disease (older, progressive, rigidity, difficulty starting/stopping movement, balance problems, gait problems)
• Other/Metabolic
  • Chronic liver disease, renal disease, profound hypokalemia, hypercalcemia, hyponatremia

Difficulty sleeping?

• Often assoc w/problems in other organ systems:
  • obstructive sleep apnea (snoring, obese, observed apnea, poorly rested in AM, daytime fatigue)
  • hyperthyroidism (also: irritability, diarrhea, palpitations, tremor, heat intolerance)
  • nocturia - BPH (w/other suggestive GU Sx - under Urinary section)
  • meds (nocturnal diuretics, caffeine, etoh)
  • mental illness - depression, anxiety

Feeling well (or poorly) in general?

Recent medical evaluations or treatments?

• Patients sometimes neglect to mention evaln/rx by other MDs/Clinics, ERs, hospitals, etc

Chronic pain?

• often underappreciated and under addressed

Vision

Chronic or past eye disorders?

• glaucoma, macular degeneration, DM retinal disease

Decrease/change in vision or blurriness? With or without pain?

• Acute
  • Painless
    • Retinal artery occlusion (unilateral, other Cardio-Vascular Risk Factors (C/V RFs))
    • Retinal vein occlusion (unilateral, other C/V RFs)
    • Retinal detachment (unilateral, floaters, flashes)
    • Vitreous hemorrhage (unilateral, diabetes, trauma)
    • Stroke (acute, loss of specific visual field, other C/V RFs)
  • Painful
    • Acute angle glaucoma (unilateral, red)
    • Infection - any eye/peri-orbital structure aside from conjunctiva (unilateral, discharge, red, trauma, foreign body)
    • trauma
• Slow & painless
  • Macular degeneration (initially vague, ultimately central field loss, uni or bilateral)
  • Refractive errors: near or far sighted (bilateral)
  • Cataract (uni or bilateral)
  • Glaucoma (uni or bilateral)

Double vision?

• dysfunction of nerves and/or muscles that move eye → loss of coordinated bilateral movement
  • Stroke (acute, other neuro Sx, C/V RFs)
  • myasthenia gravis (slowly progressive, generalized muscle weakness, worse w/use, improves w/rest)

Eye discharge (D/C)?

• Conjunctivitis (conunctival redness, itching, painless, no visual change, uni- or bilateral)
• other infectious, allergic

Change in color of structures?

• conjunctivitis (redness, discharge, painless, no visual change, uni- or bilateral)
• sub-conjunctival hemorrhage (no d/c, no pain, no visual sx, unilateral)
• jaundice: hyperbilirubinemia from liver dz, hemolysis

Head and Neck (H&N)

Chronic or past head and neck disorders?

Pain?

• infection, inflammation, trauma

Sores or non-healing ulcers in/around mouth?

• Malignancy: Squamous cell CA (RFs for CA: smoking, drinking, chewing tobacco)
• Infection: Herpes Simplex Virus
• other inflammatory: apthous ulcers

Masses or growths?

• malignancy - particularly if RFs for CA of H&N
• infection (acute, painful)

Change in hearing acuity?

• Conductive - outside → in to level of CN 8
  • external canal obstruction:
    • wax (slow, uni- or bilateral, painless)
    • bony growth (slow, uni- or bilateral, painless, hx extensive swimming)
  • middle ear:
    • tympanic membrane perforation (acute, trauma, discharge, pain)
    • effusion → following Sx otitis media (ear pain, acute, cough, nasal congestion)
• Sensori-Neural - level of CN8 to brain
  • age and noise related (slow, bilateral, older)
  • acoustic neuritis (abrupt, unilateral)
  • acoustic neuroma (unilateral, tinnitus, balance problems)
• Mixed sensori-neural and conductive

Ear pain or discharge?

• middle ear infection → otitis media (acute, cough, nasal congestion)
• outer ear → otitis externa

Nasal discharge, post nasal drip?

• Infection - e.g. rhinosinusitis
  • Viral (acute, cough, colored D/C, self limited)
  • Bacterial (acute, cough, persistent, colored D/C, fever, tooth or facial pain)
• Allergic rhinitis (chronic, cough, clear D/C)

Change in voice/hoarseness?

• Vocal cord pathology
  • Cancer (red flags: progressive, cough, hemoptysis, smoking, SOB)
  • Nodules/polyps (slow, worse w/talking, improves w/rest)
  • Infection (acute, pain w/talking, cough)
  • GERD (epigastric discomfort, radiates upward under sternum, worse lying down, bad taste in mouth, chronic/recurrent)

Tooth pain or problems?

• Dental infection, poor chronic care, lack of access to dentists

Pulmonary

Chronic or past pulmonary disorders?

• COPD, asthma, other

Shortness of breath - @ rest or w/exertion?

• Pulmonary parenchymal disease
  • Pneumonia (acute, cough, sputum production, fever, chest pain)
  • Cancer (sub-acute, cough, wt loss, hemoptysis, smoking and/or asbestos exposure, chest pain)
  • COPD (acute or chronic, cough, smoking, wheezing)
  • Asthma (acute or chronic, wheezing, cough)
• Pulmonary vascular disease
  • Pulmonary emboli (acute, cough, chest pain w/breathing, hemoptysis, RFs for Deep Vein Thrombosis (DVT))
• Pleural disease
  • Effusions
    • cancer (SOB, sub-acute, cough, wt loss)
    • infection (acute, F, cough, sputum, SOB)
    • CHF (C/V RFs, orthopnea, PND, lower extremity edema)
• Chest wall/diaphragm
  • Neuromuscular disease (generalized weakness, other neuro Sx)
  • phrenic nerve injury (post thoracic surgery)
• Many non-pulmonary
  • CHF (C/V RFs, orthopnea, PND, lower extremity edema), anemia (fatigue), deconditioning (inactivity), etc

Chest pain?

• Pneumonia (acute, cough, SOB, sputum production, fever)
• Cancer (sub-acute, SOB, cough, wt loss, hemoptysis, smoking and/or asbestos exposure)
• Pulmonary emboli (acute, cough, SOB, pleuritic, hemoptysis, RFs for DVT)
• Pneumothorax (acute, SOB, pleuritic, trauma, smoker)
• C/V disorders
  • Increased likelihood if + C/V RFs: Smoking, diabetes, early family history, male, age >~ 50, HTN, Hyperlipidemia
  • angina (other C/V RFs, squeezing/crushing type pain, provoked w/walking, radiation to arms/neck/back, sweating, N)
  • Aortic dissection (C/V RFs, tearing type CP, radiation to back)
• GI Disorders
  • GERD (sub-sternal pain radiating upwards, bad taste in mouth, worse lying down)
  • Esophageal spasm
• Musculoskeletal (worse w/movement, Hx overuse/injury), Trauma

Cough?

• Intrinsic lung pathology
  • Infection
    • Pneumonia (fever, colored sputum, SOB, acute, systemic Sx)
    • Uncomplicated upper respiratory infxn (acute, colored sputum, nasal d/c, post nasal drip, sore throat)
    • Acute Exacerbation Chronic bronchitis - AECB (Hx COPD, Sob, colored sputum, wheezing, acute)
  • Asthma (acute or chronic, wheezing, SOB)
  • COPD (acute or chronic, sputum, wheezing, SOB, smoking)
  • Cancer (SOB, known cancer, wt loss, smoking, asbestos, chest pain, hemoptysis, sputum)
• Non-pulmonary
  • GERD (heartburn, chronic)
  • Rhinitis (post nasal drip, chronic or acute)

Hemoptysis (coughing up blood)?

• Cancer (persistent, smoking and/or asbestos exposure, SOB, cough)
• Infection: bronchitis, pneumonia (acute, sputum, fever, SOB)
• Pulmonary embolism (acute, cough, SOB, pleuritic, hemoptysis, RFs for DVT)
• Other parenchymal or vascular inflammatory process

Wheezing?

• Asthma
• Emphysema
• pulmonary edema aka - "cardiac asthma" - Sx CHF (C/V RFs, orthopnea, PND, lower extremity edema)

Snoring or stop breathing?

• sleep apnea (obesity, snoring, witnessed apnea, not rested when awaken, day time fatigue)

Cardiovascular (C/V)

Chronic cardiovascular disorders?

• Hypertenion, hyperlipidemia, congestive heart failure, valvular heart disease, coronary artery disease, peripheral vascular disease, stroke, etc

Chest pain (CP) or pressure?

• C/V disorders
  • Increased likelihood if + C/V RFs: Smoking, diabetes, early family history, male, age >~ 50, HTN, Hyperlipidemia
  • angina (other C/V RFs, squeezing/crushing type pain, provoked w/walking, radiation to arms/neck/back, sweating, N)
  • Aortic dissection (C/V RFs, tearing type CP, radiation to back)
• Non-cardiac
  • GERD (sub-sternal pain radiating upwards, bad taste in mouth, worse lying down)
  • Esophageal spasm
  • pulmonary embolism (acute, cough, pleuritic, hemoptysis, SOB, RFs for DVT)
  • pneumothorax (acute, pleuritic, SOB)
  • musculoskeletal (trauma, worse w/movement)

Shortness of breath - @ rest or w/exertion?

• CHF (C/V RFs, orthopnea, PND, lower extremity edema)
• CAD (other C/V RFs, pressure w/walking, radiation to L arm/neck/back, sweating, N)
• Valvular heart disease - in particular: aortic, mitral - often w/Sx CHF
• Other non-cardiac - deconditioning (inactivity), COPD (acute or chronic, cough, smoking, wheezing), anemia (Hx suggestive blood loss), etc

Orthopnea (short of breath lying down)?

• CHF (C/V RFs, orthopnea, PND, lower extremity edema)
• COPD (acute or chronic, cough, smoking, wheezing)

Paroxysmal Nocturnal Dyspnea (PND)? - sudden shortness of breath that awakens pt from sleep

• CHF(C/V RFs, orthopnea, PND, lower extremity edema)

Lower extremity edema?

• Bilateral:
  • Hydrostatic:
    • L sided CHF → systolic and diastolic dysfxn
    • R sided CHF → pulmonary htn, L sided CHF
    • Portal htn → cirrhosis
  • Low oncotic pressure
    • Advanced liver disease
    • Malnutrition
    • Loss of protein in urine → nephrotic syndrome
    • Venous insufficiency (worse after standing, dark skin discoloration)
    • General volume overload:
      • cirrhosis (chronic liver dz → hep C, ETOH)
      • renal failure
• Unilateral edema → local problem
  • Infection (redness, pain, fever)
  • DVT (acute, localized discomfort, RFs: hypercoaguable state, immobility, trauma)
  • Lymphatic obstruction
    • lymphatic injury (lymph node dissection, trauma)
    • obstructing cancer
  • Venous insufficiency (Hx saphenous vein harvest w/CABG, worse after standing, dark skin discoloration)

Sudden loss of consciousness (syncope)?

• Cerebral hypoperfusion
  • Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
  • Bradycardia (fatigue, decrease exercise tolerance, CHF Sx)
  • SVT (rapid/irreg heart beat, palpatations)
  • Aortic stenosis (progressive, known valvular heart disase, SOB/DOE)
  • hypovolemia (bleeding, diarrhea, Sx provoked by standing)
  • Orthostatic blood pressure change from autonomic dysfunction (Hx diabetes, other neuropathy)
• Non-cardiac
  • Seizure d/o
  • hypoglycemia (known DM & Rx w/meds)

Sense of rapid or irregular heart beat, palpatations?

• Supraventricular tachycardia (SVT): atrial fibrillation, atrial flutter, a-v nodal re-entrant tachycardia
• Ventric tachycardia (red flags: syncope/presyncope, abrupt, resultant fall w/injury, Hx CAD, Hx CHF)
• Premature ventricular contraction, atrial premature contraction (awareness of extra beat, early beat, strong beat; No SOB, CP, CHF Sx, presyncope/syncope)

Calf/leg pain/cramps w/ambulation?

• Peripheral Arterial Disease - PAD (progressive, C/V RFs)
• Spinal stenosis (radiates down back both legs, worse w/walking, better leaning forward)

Wounds/ulcers in feet? Difficult/slow to heal?

• Non-specific - often assoc w/PAD, Diabetes, poor nutrition, immune compromised, or combinations

Gastrointestinal

Chronic or past GI disorders?

• ulcers, hepatitis, inflammatory bowel disease, cancer, irritable bowel syndrome, etc

Heart burn/sub-sternal burning?

• Gastroesophageal Reflux Disease (worse after meals, worse if lie down after eating, bad taste in mouth)

Abdominal pain?

• Acute Upper Abd
  • Gastroenteritis (self limited, N, V, D, others similarly ill)
  • Peptic ulcer Dz (epigastric, better or worse w/food, nsaid use, black stools, hematemesis)
  • Pancreatitis (epigastric, constant, radiates to back, N, V, ETOH abuse)
  • Cholecystits (constant, right/upper abd, fever, nausea)
  • Biliary colic (episodic, after meals, right upper quadrant)
• Chronic/Upper abd
  • GERD (epigastric, radiates upward under sternum, worse lying down, bad taste in mouth)
  • Non-ulcer dyspepsia (epigastric, better or worse w/food; no red flags)
  • Abdominal Cancer - primary or metastatic
    • Gastric (red flag Sx: anorexia, weight loss, epigastric, persistent/progressive, N, V, early satiety)
    • Pancreatic (red flag Sx: anorexia, weight loss, epigastric pain radiating to back, persistent/progressive)
    • Liver (red flag Sx: anorexia, weight loss, right upper quadrant, persistent/progressive, Hx chronic Hepatitis)
    • Biliary (red flag Sx: anorexia, weight loss, epigastric/right upper quadrant, persistent/progressive, jaundice, ictreus, white stools)
    • Colon (red flag Sx: anorexia, weight loss, vague pain, persistent/progressive, bloody stools, change in bowel habits, pain w/defecation)
    • Lymphoma (red flags: wt loss, sweats, adenopathy elsewhere)
• Acute Lower abd
  • Bowel obstruction (comes in waves, generalized, N, V, decreased flatus, abd distention)
  • Renal stones (colicky, radiates from flank towards pelvis, N, V, hematuria)
  • Diverticulitis (left/lower abdomen, fever, nausea)
  • Appendicits (starts umbilicus → R lower queadrant, fever, nausea)
  • Abdominal aortic aneurysm (vague umbilical Sx, radiating to back, C/V RFs)
  • Hernia - incarcerated or strangulated (inguinal area, severe)
  • GYN
    • Ectopic pregnancy (sharp, vaginal bleeding, sexually active)
    • Pelvic inflammatory disease (vaginal D/C, fever, sexually active)
    • Ovarian etiology
      • cyst rupture (mid-menstrual cycle, gradual onset)
      • torsion (severe, N, V)
• Chronic lower abd
  • Functional constipation (no red flags)
  • Inflammatory Bowel Disease - upper or lower abd (sub-acute, recurrent or chronic; wt loss, diarrhea, bloody stools, cramps, constipation; presentation can also be fulminant)

Difficulty swallowing?

• esophageal mechanical obstruction
  • malignant stricture (red flags: progressively worse w/time, food "sticks" in same place, wt loss, RFs:
    • smoking, ETOH abuse, long standing reflux)
  • benign stricture
    • web or ring, GERD related stricture (long Hx GERD)
• dysmotility - e.g. achalasia, esophageal spasm

Pain upon swallowing?

• Esophageal inflammation
  • viral/fungal infection (acute, often immune compromised)
  • pills (acute, occurs after a pill stuck)

Vomiting?

• impaired gastric emptying
  • malignancy (red flags: age > 50, wt loss, smoking, after each meal, progressive)
  • autonomic nerve dysfunction - e.g. w/DM (neuropathic Sx elsewhere)
  • benign stricture (Hx ulcers)
• gastroenteritis (acute, w/diarrhea)
• small or large bowel obstruction (abd pain, distention, Hx surgery → adhesions, decreased flatus, decreased bowel movements)
• many non-GI etiologies - e.g. increased intracranial pressure (HA, trauma, cancer), meds, toxins, etc

Abdominal swelling or distention?

• Fluid within peritoneum → ascites (known cancer, advanced liver disease, TB/chornic infxn)
• gas, organomegaly, ventral hernia (past surgery, bulge thru scar line, increases w/straining)

Jaundice (yellowish coloration of skin)?

• hepato-biliary disease → failure to excrete conjugated bilirubin
  • Stone in common bile duct (acute, if also infxn: RUQ pain, F, N, systemic illness)
  • Common duct or pancreatic cancer (sub-acute, painless, age > 50, wt loss)
  • Chronic liver dz - Hep C, Etoh (long duration illness)
• Hemolysis

Vomiting blood (hematemasis)?

• Bleeding in upper GI tract
  • Ulcer (epigastric, better or worse w/food, nsaid use, black stools)
  • varices (chronic liver disease → portal hypertension)
  • gastritis (stress, ETOH), esophagitis (GERD Sx)

Black/tarry stools?

• Bleeding in upper GI tract
  • Ulcer (epigastric, better or worse w/food, nsaid use, black stools)
  • varices (chronic liver disease → portal hypertension)
  • gastritis (stress, ETOH), esophagitis (GERD Sx)

Bloody stools?

• Bleeding in lower GI tract
  • AVM, polyp, diverticulum, cancer, hemorrhoid, inflammation from IBD or other

Constipation?

• Functional: low fiber diet, Irritable Bowel Syndrome (chronic, crampy pain, no wt loss, no blood in stool; no systemic Sx; occasional diarrhea)
• Hypothyroid (wt gain, edema, dry skin, constipation, cold intolerance, depression, hair loss)
• Obstruction: distal cancer (red flags: sig pain, blood, wt loss, progressive)

Diarrhea or other change in bowel habits?

• structural problems: distal colon malignancy (red flags: progressive, wt loss, pain, blood in stool, nocturnal diarrhea); benign stricture
• inflammatory disorders:
  • Inflammatory Bowel Disease (sub-acute, recurrent or chronic; wt loss, bloody stools, mucous, cramps, constipation, nocturnal diarrhea; systemic Sx; presentation can also be fulminant)
  • Infections: acute bacterial (F, abd pain), viral (fever, abd pain); chronic e.g. parasites, HIV
• malabsorptive d/o: celiac dz (chronic, wt loss), pancreatic insufficiency (Hx chronic/recurrent pancreatitis)
• Irritable Bowel Syndrome/Functional (chronic, no wt loss, crampy pain, no systemic Sx, no blood, sometimes constipation)
• other non GI: hyperthyroidism (irritability, inability to sleep, weight loss, palpitations, tremor, heat intolerance), laxative abuse, excessive caffeine intake, etc.

Genito-Urinary

Chronic or past GU disorders?

• BPH, cancer, stones, intrinsic renal disease, etc

Blood in urine?

• Malignancy of GU tract (red flags: persistent gross blood, age > 50, male, hx smoking)
• Stones (pain, frequency)
• Infection (acute, pain, frequency, urgency, fever)
• Other causes red or dark urine not from blood:
  • myoglobin
    • rhabdomyolysis: muscle breakdown → extreme muscle activity
    • meds → statins
  • bilirubin (jaundice, chronic liver disease)

Burning with urination?

• simple UTI (acute, frequency, urgency, no vaginal d/c if female, no other Sx)
• complex infection/pyelonephritis (fever, chills, lower abd/low back pain)
• other e.g. stones, malignancy

Urination at night?

• Benign Prostatic Hypertophy - BPH (chronic, progressive, urgency, frequency, hesitancy, difficulty starting/stopping stream, incomplete emptying, decrease force, voiding again soon after urinate)
• AUA BPH Symptom Index (ACP)
• Over production of urine e.g. diabetes
• Meds/drugs: diuretics, ETOH
• CHF → redistribution of volume w/lying down

Incontinence (unintentional loss of urine)?

• Disorders of urine storage
  • Detrussor over activity (sudden urgency)
  • Detrussor under activity
• Disorders of bladder outlet resistance
  • Increased resistance: BPH (see above - urination @ night), urethral stricture (hx STI, trauma)
  • Decreased resistance: stress incontinence (women > 50, childbirth, worse w/cough/sneeze/sudden movement); complication of prostatectomy
• Non-GU based
  • excess urine production → poorly controlled DM, diuretic use
  • among older patients
    • infection, confusion, immobility, etc

Urgency?

• BPH, infection, cancer, stone
• if very strong and sudden → detrussor over activity

Frequency?

• primary GU
  • BPH, infection, cancer, detrussor instability, stone
• non-GU
  • DM, diuretic use, etc

Incomplete emptying? Hesitancy? Decreased force of stream? Need to void soon after urinating?

• BPH AUA BPH Symptom Index (ACP)
• decreased bladder contraction (peripheral neuropathy - sensory or motor)
• urethral stricture (men: Hx urethral trauma, Hx gonorrhea)

For Men:

Errectile Dysfunction (ED)?

• problem with libido/lack of interest
• problem getting and maintaining errection capable of performing desired activity (C/V RFs as ED assoc w/vascular dz, neuropathy Sx)

Penile d/c or pain?

• Sexually Transmitted Infection (STI) - Gonorrhea or Chlamydia

Testicular pain?

• Infection (pain w/urination, penile D/C)
• torsion (acute, unilateral, severe)

Testicular swelling, mass?

• Cancer (progressive, painless), hydrocele (painless)

Fertility problems?

Hx STIs?

• Increased risk for: HPV, HIV, Hepatitis B, Syphilis, other

# Sexual partners & type of sexual activity?

• Risks as per STIs

Hematology/Oncology

Chronic or past Heme/Onc disease?

• solid or liquid malignancies; benign hematological diseases, etc - employ multi-system ROS to define

Fevers, chills, sweats, weight loss?

• Non-specific - could be from many malignancies - also infection, autoimmune disorders

Abnormal bleeding/bruising?

• Defect in clotting system
  • Platelets
    • low quantity
    • impaired function from: aspirin, clopidogrel, renal failure, other
  • impaired intrinsic or extrinsic pathways → e.g. coumadin use

New/growing lumps or bumps?

• Adenopathy
  • lymphoma, metastatic disease
  • infection
    • acute
      • bacterial or viral
    • chronic
      • TB, HIV
• masses - primary CA in an organ v metastatic disease v other

Hypercoaguability?

• Hx DVTs, Pulmonary Emboli

Ob/Gyn/Breast

Chronic or past disease?

• Infertility, endometriosis, infection, cancer, etc

Menstrual Hx?

Sweats?

• peri-menopause (hot flashes, vaginal dryness, age near ~50)

Past pregnancies?

• # went to term? complications? infertility?

Vaginal Discharge??

• Vagniniitis: fungal, bacterial (acute, odor, itch, irritation)
• Cervicitis: STI (discharge, lower abd/pv pain, sexually active)

Therapeutic or spontaneous abortions?

Hx STIs?

• Increased risk for:
  • infertility → tubal scarring via PID
  • cervical CA via HPV
  • HIV, Hepatitis B, syphilis, other

# Sexual partners & type of sexual activity?

• Risks as per STIs

Breast mass, pain or discharge?

• Mass
  • malignancy (increase w/time, firm)
  • benign → cysts, fibrous tissues (size varies w/menstrual cycle)
• Discharge
  • benign
    • milk, cyst fluid
  • malignancy (bloody)
  • milk when not post partum or male → increased prolactin (HA, visual Sx, infertility)
• pain suggests inflammation - mastitis (post partum), cancer, cyclic (partic time of menstrual cycle)

Neurological

Known disease?

• Stroke, seizure, neurodegenerative - Multiple sclerosis, ALS, etc

Sudden loss of neurological function?

• acute weakness and/or numbness suggests vascular event:
  • stroke if loss is persistent; TIA if transient

Abrupt loss/change in level of consciousness?

• Seizure d/o
• Cerebral hypoperfusion
  • Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
  • Bradycardia (fatigue, decrease exercise tolerance, CHF Sx), SVT (rapid/irreg heart beat, palpatations)
  • hypovolemia (bleeding, diarrhea, Sx provoked by standing)
  • Aortic stenosis (progressive, known valvular heart disase, SOB/DOE)
  • Orthostatic blood pressure change from autonomic dysfunction (Hx diabetes, other neuropathy)
• drug use/overdose/toxin, trauma, hypoglycemia, delirium, etc

Witnessed seizure activity?

• Primary Seizure d/o
• Secondary szr
  • Cerebral hypoperfusion
    • Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
    • Bradycardia (fatigue, decrease exercise tolerance, CHF Sx), SVT (rapid/irreg heart beat, palpatations)
    • hypovolemia (bleeding, diarrhea, Sx provoked by standing)
    • Aortic stenosis (progressive, known valvular heart disase, SOB/DOE)
    • Orthostatic blood pressure change from autonomic dysfunction (Hx diabetes, other neuropathy)
  • Hypoglycemia, drug use/overdose/toxins, trauma

Numbness?

• Suggests sensory abnormality - e.g. central or peripheral nerve dysfunction
• Other metabolic: thyroid, hypocalcemia, other

Weakness?

• generalized etiology - e.g. deconditioning, poor nutrition, anemia, combinations etc
• primary neuro-muscular d/o → Guillain Bare, Myasthenia Gravis, ALS, myositis (progressive, muscle weakness)

Dizziness?

• Vertigo - sensation of movement when none occurring
  • Central:
    • stroke (other C/V RFs, acute, other focal neurological complaints)
    • tumor
  • Peripheral
    • labrythitis (abrupt, worse w/movement, self limited, URI Sx prior)
    • benign positional vertigo (acute, worse w/movement, no other neuro Sx, prior trauma, usually self limited)
    • Meniere's Disease (tinnitus, waxes and wanes, unilateral, hearing loss)
• Syncope or presyncope
  • Cerebral hypoperfusion
    • Ventricular dysrhythmia (red flags: abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
    • Bradycardia (fatigue, decrease exercise tolerance, CHF Sx), SVT (rapid/irreg heart beat, palpatations)
    • hypovolemia (bleeding, diarrhea, Sx provoked by standing)
    • Aortic stenosis (progressive, known valvular heart disase, SOB/DOE)
    • Orthostatic blood pressure change from autonomic dysfunction (Hx diabetes, other neuropathy)
  • Non-cardiac
    • Seizure d/o
    • hypoglycemia (known DM & Rx w/meds)
• Disequilibrium
  • impaired sensory inputs (vision, hearing, peripheral neuropathy, muculoskeletal, other)
    • when standing/walking

Balance problems?

• generalized weakness, peripheral neuropathy, visual problems, cerebellar d/o, combinations

Headache?

• Chronic "benign"
  • migraine (recurrent, last many hours, severe, throbbing, sometimes aura, assoc w/ N, V, light & sound sensitivity, unilateral)
  • tension (recurrent, bi or uni-lateral, dull, no migraine/other sx)
  • cluster (recurrent, brief, severe, focused around eye/temporal area, assoc w/tearing/rhinorrhea)
  • other - e.g. mixed types
• Intrinsic head pathology
  • bleeding (red flags: acute onset, altered consciousness, other focal neruo symptoms)
  • tumor (red flags: age > 50, known primary or secondary tumor, other focal neuro symptoms)
  • infection (red flags: acute, fever, neck pain/stiffness, light sensitivity, confusion)
• Non-neuro
  • Depression
  • Eye strain
  • Sinusitis (acute, post nasal drip, facial pain, nasal d/c, cough)
  • Generalized viral or bacterial infections
  • temporal arteritis (older, acute, jaw pain w/chewing, Hx Polymyalgia, neck/shoulder aches, decreased vision)

Tremor?

• Intrinsic neurological d/o
  • benign essential tremor (chronic, worse w/activity, no other sx)
  • Parkinson's disease (older, progressive, rigidity, difficulty starting/stopping movement, balance problems, gait problems)
• Non-neuro
  • Hyperthyroidsim (irritability, inability to sleep, diarrhea, palpitations, tremor, wt loss, heat intolerance)
  • sympathomimetics/stimulants → caffeine, ritalin, cocaine

Endocrine

Known Endocrine disorder?

• Diabetes, hypo/hyperthyroidism, etc

Polyuria, polydypsia, polyphagia?

• Poorly controlled dm

Fatigue?

• Hypothyroidism (wt gain, edema, dry skin, constipation, cold intolerance, depression, hair loss)
• Many other endocrine, non-endocrine → see under general

Weight loss?

• Hyperthyroidism (irritability, inability to sleep, diarrhea, palpitations, tremor, heat intolerance)
• Many other endocrine, non-endocrine → see under general

Weight gain?

• Hypothyroidism
• "typical" obesity (too mnay calories, too little activity)
• many other endocrine, non-endocrine → see under general

Infectious Diseases

Known disease?

• TB, HIV, endocarditis, chronic hepatitis B or C, immune compromised state, other
  • acute or chronic infections, etc

Fevers, Chills, Sweats?

• Non-specific - associated w/acute and chronic infection - though non-infectious as well - e.g. cancer, auto-immune disease
• Localize Sx to specific organs on basis of other ROS questions → identify site of infection
  • urinary burning, frequency, urgency → simple UTI
  • cough, sputum, SOB → Pneumonia

Musculoskeletal

Known disease?

• Degenerative joint disease/Osteoarthritis, Rheumatoid Arthritis, Lupus, gout, etc.

Joint pain?

• Inflammatory
  • Gout (acute, worse w/movement, one or few joints - commonly great toe, male >> female)
  • Infection (acute, worse w/movement, one or few joints, fever, chills)
  • RA (persistent/progressive; bilateral: MCPs hands, knees; warmth; redness; worse in am; women > men; fatigue; systemic Sx)
• Non-inflammatory
  • DJD (subacute/chronic, worse w/activity, slowly progressive, prior injury, wt bearing joints (knees, hips))
  • Knees specific - structural damage to ligaments, menisci (swelling, locking, give-way, Hx discrete injury)
  • Other, non-joint related pathology - e.g. arthralgias from systemic illness

Joint swelling?

• Inflammatory
  • infection v non-infectious
• DJD, Trauma

Joint redness?

• Suggests inflammation - infection v non-infectious

Low back pain?

• DJD/non-specific musculo-skeleatal (waxes/wanes, no red flags or other Sx)
• Nerve root irritation from disc or DJD → "sciatica" (waxes/wanes, radiates down leg)
• spinal stenosis (older, slowly progressive, worse standing, radiates down B legs w/walking)
• Cancer (red flag sx: unremitting, known hx cancer, wt loss, > 50, sweats/systemic sx, other neuro c/o)
• Fracture (older, trauma, unremitting)
• Local infection (red flags: unremitting, known systemic infection, fever, chills, acute/sub-acute)
• Cauda equina (red flags: acute, altered bowel/bladder fxn; loss other neruo fxn)
• Distant disorders
  • Retroperitoneal:
    • Abdominal Aneurysm (age > 50, C/V RFs, abd sx w/radiation to back)
    • Renal stone (acute, severe, colicky, radiates towards abd/pv)
    • Renal infection (acute, F, C, N, dysuria, urinary frequency)
  • Intra-abdominal: pancreatitis (acute, N, V, ETOH abuse)
• Systemic infection: endocarditis (F, sweats, abnormal/prosthetic valves, systemic Hx, Hx bacteremia)
  • viral syndromes

Mental Health

Known mental health disorder?

• depression, anxiety, schizophrenia, etc

Do you feel sad or depressed much of the time?

• depression
• PHQ-9 Depression Screen

Alcohol, other substance abuse?

• depression, substance abuse d/o

Anxious much of the time?

• Anxiety d/o, substance abuse, depression

Memory problems?

• Assoc w/dementia, other - define with Mini Mental Status Exam (MMSE)

Confusion?

• delirium (acute, older, secondary to toxic/metabolic process)
• dementia (older, progressive, memory deficits - define w/ Mini Mental Status Exam (MMSE)
• Comprehensive Mental Status Exam - to help define mult thought/cognitive issues

Skin and Hair

Known disease?

• cancer, psoriasis, alopecia, etc

Skin eruptions/rashes?

• Infection, inflammatory, other

Growths?

• Benign and malignant

Sores that grow and/or don't heal?

• malignancies - e.g. melanoma, basal cell, squamous cell

Lesions changing in size, shape, or color?

• malignancies - e.g. melanoma, basal cell, squamous cell

Itching?