Review of Systems Flashcards
Why do you do a review of systems?
- ROS + HHx form + PT’s follow-up questions = full picture of patient’s health
- Determines whether you should treat, refer, or consult
- Can come up with differential diagnoses and begin to eliminate them
- Want to look for red or yellow flags
What is a differential diagnosis?
When flags come up, you brainstorm all possible diagnosis then you can test them and eliminate.
A patient comes in with no red flags or yellow flags. What decision do you make?
A keep decision. I am not concerned about treating them. It is in my area of expertise, and it is an orthopedic concern.
If a patient comes in with a negative neuro examination but a few neuro signs, what decision do you make? They also have saddle anesthesia.
Those are some yellow flags, and with some yellow flags I would consult. I am slightly concerned, and I need a better opinion before testing them.
What does a yellow flag indicate?
It indicates something concerning. It warrants additional observation, testing, consult with another provider. Is the PCP aware of the condition? Is the condition worsening? If so, how quickly?
What does a red flag indicate?
An emergent or urgent situation. A serious pathology requiring referral to and/or communication with another specialist.
If a patient comes in with a hip fracture or hypermobility syndrome, what would you do?
Those are both red flags, so I would refer. I don’t feel safe and comfortable treating them. There are red flags, and it is out of my realm. I need you to go to someone else before I treat you.
How do you perform an ROS?
- Ask responses to HHx
- Recent changes to health status
- Concerns about health status
- Observation
- Probing questions
Prepare questions beforehand
Does their body language match their Dx?
What are Pt demographics, and why are they important?
Age, gender, race, marital status, education
They are important because some Dx are more common in different races. People’s experiences with health care will also have been affected by biases in the medical system and culture.
What are culture, religion, occupation, living environment, and family/social support examples of?
Social History
What are things you find in the PMHx?
Allergies, illness, surgeries, and medication
What is recreational use of alcohol an example of?
Social habits. Other examples include exercise and substance abuse/use. You can ask hard questions like recreational alcohol use, but be open and tactful.
What is another section on most health history forms?
Family medical history. Ask about parent’s heart attack like how old they were, etc.
Hypo/hypertensive emergency
A red flag.
Severe increase in BP can lead to stroke.
Too low needs to be addressed as well
Spine CA
Red flag
Spinal tumor
Symptom Ex: radiating back pain that gets worse at night
Fatigue vs. Malaise
General health component
Fatigue accounts for approx 20% of PCP visits in the US. It can be caused by meds, infection, CA, endocrine disease, psychological conditions, or it could be explained.
Malaise is a systemic condition. It is the uneasiness that something is not right.
Fever, chills, and sweats
General health component
It is a red flag when…
equal to or above 102, above 104 should go to the hospital, unknown cause, present for 2-3 weeks, accompanied by other symptoms: mentation, malaise, fatigue.
Infants and babies can have fever seizures. This is not too concerning, so you can ask when and why someone had a seizure.
Unexplained weight loss
General health component
Weight loss is more common. Possible Dx ex: depression, CA, GI disease, cardio disorders.
Weight gain: fluid retention. Possible Dx ex: CHF, renal or liver disease, preeclampsia.
Concerning: 5-10% weight change over 6 months with no explanation. Except pregnancy where an increase of 5 lbs in 1 week is a concern.
Nausea and vomiting
Duration and frequency of symptoms
Dehydration is a concern
Green-yellow: biliary colic (gall bladder)
Bilious vomit: intestinal obstruction
Coffee grounds: hematemesis (blood)
This is most concerning when it is paired with something, or if it is all the time and unexplained.
Paresthesia, numbness, or weakness
Many conditions we treat have these symptoms, so it is especially important to check when our patients are reporting with back/neck pain.
Concerning: bowel and bladder changes, progressive strength and sensory changes, saddle anesthesia, glove and stocking distribution, bilateral extremity symptoms, associated fatigue
If these come up, you must perform a complete neurological examination. If it is negative, then some neuro signs can be yellow flags.
Look for abnormal things or changes.
Dizziness or lightheadedness
Vestibular-vertigo or BPPV Cardiac (BP) Vertebrobasilar Insufficiency (VBI) Vasovagal syncope response Complete balance testing and ask follow up questions
Change in mentation
Level of consciousness Attention Memory Orientation Judgement Progression and speed of changes Other people may notice changes in someone's mentation more than the patient.
Pelvic tumor
May or may not be cancerous. Symptoms include pain in pelvis, swelling, bloating, vomiting, and nausea
Spine compression fx
When the bony block or vertebral body collapses. Commonly in T-spine. Back pain when walking or standing
Spinal infection
Pain localized at the site of infection. Vertebral osteomyelitis most common. Severe back pain, fever, chills, weight loss.
Neck fx
Red flag
VBI
Vertebrobasilar insufficiency: symptoms include loss of vision, double vision. It is due to lack of blood to the posterior portion of the brain.
Cervical instability
Loose ligaments may lead to neuronal damage
Cauda equina syndrome
Dysfunction of multiple lumbar and sacral nerve roots of the cauda equina, most commonly from a herniated disk
Hip fx
Red flag
Post concussion/post-closed head injury
Red flag
Myelopathy
Injury to spinal cord due to severe compression from trauma, congenital stenosis, degenerative disk
Hypermobility syndrome
Very flexible joints can cause pain
Suicide/abuse
Red flag
What is most important about Review of Systems?
Make sure you look at the whole person
