A thorough history and physical exam, including a review of systems, is important to do with every patient so that critical diagnoses aren’t missed.
In medical school, we’re taught to take a thorough history of every patient that we see. Unfortunately, in clinical practice, sometimes it’s not practical to spend a lot of time taking those histories. There may also be time constraints, other patients that need to be seen, administrative tasks to take care of, prescriptions to be signed off, all part of an endless list of tasks.
Therefore, it’s very tempting to skip certain parts of the history to expedite the process and move on to the next patient or next task. This is especially true while working in the often busy emergency department (ED). You’ll want to focus on the chief complaint (CC) (or, the primary reason that they came to the ED) and subsequently, order labs or imaging to address that CC.
However, slowing down and taking a minute to briefly go through a complete review of systems (ROS) can potentially lead to the diagnosis and treatment of an underlying, unknown medical issue. An ROS is a set of questions that are asked to do a quick survey of the entire body’s organ system. The following post is about a patient whose case highlighted the importance of a quick, however thorough, ROS.
The Patient Case Study
A 40-year-old female went to the emergency room for evaluation of left-sided abdominal pain. This abdominal pain had been progressively worsening over the past three months. She doesn’t have any other typical gastrointestinal symptoms, like issues with going to the restroom, blood in her stool, nausea, vomiting, or fever.
She has no other medical issues, has never had cancer, any surgeries, and doesn’t smoke, drink alcohol, or abuse drugs. Her physical exam didn’t reveal any abdominal pain and was otherwise unremarkable.
At the end of my interview, I briefly asked her some additional questions to complete a ROS. The only consistent symptom she had for the past three months was feeling short of breath when she walked, which she’d attributed to wearing a mask. The medical team decided to perform a CT scan of her abdomen to see if there was a clue to what was causing her pain.
Remarkably, the CT scan showed nothing, but a chest x-ray indicated some haziness in the lungs of her right side. A chest CT recommended for further evaluation of the haziness suggested a pleural effusion (fluid that builds up around the lungs) that could be caused by heart failure, an infection, or underlying cancer. Because her condition was potentially critical, the decision was made to admit her to the hospital, drain the fluid, and further investigate her condition.
Lessons Learned
This patient case demonstrated the importance of not skipping parts of the history taking. During my early years of medical school, I was often narrowly focusing my questions solely on the chief complaint. With this patient, had I not done a complete ROS, I wouldn’t have considered doing imaging of her chest and we would have missed her pleural effusion.
Additionally, while her shortness of breath was not relevant to her abdominal pain, her management plan was directed appropriately due to us asking for that information.
Conclusion
Even if certain parts of a ROS don’t seem relevant to the chief complaint, it’s still good practice to perform it. Not only could it change the management plan, but it can also help discover a more critical issue and pave the way for the patient to get the help that they need.
About the Author
Brian Le is an OMS-IV at A.T. Still University School of Osteopathic Medicine in Arizona. He is interested in emergency medicine. He loves to rock climb!
Stay a step ahead of your peers by using Osmosis! Sign up for a free trial today.
Leave a Reply