Review of Systems2,3 The ROS can be applied as a head-to-toe, comprehensive screening tool asked of every patient, as additional questions asked only of patients who fall in particular risk categories, or as a means to describe the likely causes of a presenting symptom. Below are the various organ systems and corresponding ROS. Keep in mind that these are just the more common symptoms and not an exhaustive list. Constitutional: weight loss or gain, general state of health, wellbeing, and strength Endocrine: polydipsia, polyuria, hormone therapy, intolerance to heat or cold, weight changes Integumentary: hair loss, skin eruptions/rashes/growths, sores that grow and/or don’t heal, lesions changing in size, shape or color, itching Immunology: reactions to drugs, food, insects, skin rashes, trouble breathing, anemia, bleeding tendency, lymph node enlargement/tenderness Musculoskeletal: joint pain, swelling or redness, muscle ache, back pain Ear/Nose/Throat: pain, mouth sores, change in hearing, poor swallowing, discharge Respiratory: shortness of breath, chest pain, cough, hemoptysis (coughing up blood), snoring or stop breathing Cardiovascular: chest pain, palpitations, syncope, dyspnea, edema, heart murmurs, varicosities Gastrointestinal: appetite changes, indigestion/heartburn, abdominal pain, nausea, vomiting, hematemesis, jaundice, constipation, diarrhea Genitourinary: urgency, frequency, dysuria, nocturia, hematuria, polyuria, unusual urine, stones, infections, nephritis, hesitancy, incontinence, genital sores, discharge, STD OB/Gyn/Breast: Chronic or past disease, dysmenorrhea, vaginal discharge, postmenopausal bleeding, dysparenia, number and results of pregnancies, breast mass, pain or discharge Neurologic: headache, convulsions, paralyses, parathesias, difficulties with memory or speech, sensory or motor disturbances, poor muscular coordination (ataxia, tremor), orientation (place, time, person) Psychiatric: predominant mood, emotional problems, anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations Hematology/Oncology: chronic/past hematologic/oncologic disease, abnormal bleeding/bruising, new growing lumps/bumps, hypercoaguability

The eye does not function in isolation. This has been apparent for a long time. Nineteenth-century physicians skilled in the diagnosis and treatment of eye diseases branched out by adding otology (ear and vestibular diseases), rhinology (diseases of the nose, including the sinuses) and laryngology (diseases of the throat and larynx) to their repertoire. These early EENT physicians viewed the eye and visual system as being closely related to these other organs, so why not treat them all? Optometrists often shared both office space and patients with audiologists, and many still do so today. Several of our optometric colleagues practice in multidisciplinary health settings.

But the connection of the visual system to the rest of the body involves far more than other tissues of the head and neck. As part of the nervous system, the eye interacts with virtually every other organ system. In our bimonthly column, we attempt to illustrate the fact that many systemic conditions have ocular complications, and several ocular diseases—and treatments—have systemic implications.

Optometrists are in a position to team with providers from various other disciplines in the interest of patient health and wellness. A dentist colleague of ours once remarked, “We do the same thing, just in different places. You see diabetic retinopathy; I see diabetic periodontitis. You treat uveitis in a patient with Crohn’s disease; I treat their aphthous ulcers (canker sore). You relieve a Sjögren’s patient’s dry eye; I enhance their diminished saliva production.”

A True Review
There are ever-growing, high-tech diagnostic methods available to us, but the simple case history usually provides 90% of the useful information, with eye examination and diagnostic tests used to confirm the diagnosis.

The clinical evaluation of any patient, no matter what the discipline, begins with a case history.

We are all familiar with the major elements of the case history, from the chief complaint to medications and allergies. The Problem-Oriented Medical Record (POMR) has proven to be a useful method for documenting medical information._¹ It provides a structure that helps us record our patient notes, and view those notes subsequently in a manner that gives us a good understanding of that patient’s history.

The review of systems (ROS) has become a standard element of the history and the POMR. ROS is a list of questions, arranged by organ system, designed to uncover symptoms of dysfunction and disease._²

Applying ROS
The ROS can be applied in several ways:
• As a head-to-toe screening tool asked of every patient.
• As additional questions asked only of patients who fall into particular risk categories (e.g., reserving questions designed to uncover pseudotumor cerebri to overweight females of child-bearing age.)
• As a means to describe the likely causes of a presenting symptom (e.g., patients with a chief concern of “unilateral eye and head pain” would merit a detailed headache and neurologic ROS).

Today’s clinicians incorporate the ROS into the overall patient care strategy. Patients’ responses should be interpreted within the context of the rest of their profile, including demographics, risk factors, past history, and objective data gained from the examination.

The clinician can then come to an informed conclusion about the extent and cause of the patient’s symptom(s), and use it to guide their subsequent management. There are few functions of the human body that operate singularly, and the visual system is no different. It’s just one part of an overwhelmingly complex structure that continually demands our insight and attention. We owe it to our patients to have a full understanding of how these systems interact so we can provide them with the best treatment and care. 
    
1. Hayes, GM. Medical records: past, present and future. Proc AMIA Annu Fall Symp. 1996:454-8.
2. Swartz MH. Review of Systems. In: Swartz Textbook of Physical Diagnosis: History and Examination. 4th ed. Philadelphia, PA: WB Saunders; 2002.
3. Bickley L. Review of Systems. In: Bates’ Guide to Physical Examination. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 1999.