2.6 Review of Systems

2.6 Review of Systems

Quick Answer: The review of systems (ROS) is a structured, subjective inquiry across body systems -- constitutional, neurological, cardiovascular, gastrointestinal/genitourinary, and psychiatric, among others -- used to uncover visceral disease or systemic illness that can masquerade as, or coexist with, a neuromusculoskeletal (NMS) complaint. On Part III, ROS items test whether you can recognize a cluster of systemic symptoms as a red flag requiring referral rather than continued conservative NMS management.

Purpose and Structure of the ROS

The review of systems is distinct from the history of present illness (HPI): the HPI explores the details of the chief complaint itself, while the ROS is a broader subjective screen of every major body system, asked regardless of whether the patient has already mentioned a related symptom. The ROS is a patient-reported inventory, not an examination finding -- it captures symptoms the patient has noticed, which then guide which parts of the physical examination deserve special attention. Findings are typically documented as "positive" (present) or "negative" (denied), and a well-documented ROS explicitly lists pertinent negatives (for example, "denies fever, chills, or unexplained weight loss") rather than leaving silence to be interpreted as a negative.

Constitutional Symptoms

Constitutional (or "general") symptoms are among the highest-yield red flags in the entire case history because they suggest a systemic process such as infection, inflammatory disease, or malignancy rather than a purely mechanical NMS condition:

Any of these findings paired with unrelenting spinal pain -- especially pain that is worse at night, unrelieved by rest or position change, and not reproduced by mechanical loading tests -- should substantially raise suspicion for infection or malignancy and prompt referral rather than continued trial of conservative care.

Neurological Review

Neurological ROS items screen both for local nerve involvement related to the NMS complaint and for signs of a neurological emergency:

• Headache pattern -- new, severe, or "worst-ever" headache; headache with fever or neck stiffness; headache following trauma
• Dizziness or vertigo -- particularly with neck movement, which raises consideration of vertebrobasilar insufficiency before upper cervical manipulation
• Numbness, tingling, or weakness -- distribution (dermatomal versus peripheral nerve versus non-anatomic) helps localize the lesion
• Bowel or bladder changes (retention, incontinence, or loss of urge) combined with saddle anesthesia and bilateral leg symptoms -- this combination defines suspected cauda equina syndrome, a surgical emergency requiring immediate referral
• Vision changes or cognitive changes -- relevant to central causes and to red flags following head or neck trauma

Cardiovascular Review

Cardiovascular ROS items are essential because cardiac and vascular disease frequently present with pain patterns that overlap with common chiropractic complaints:

A patient -- especially an older patient with vascular risk factors -- presenting with new, severe back pain described as "tearing" or "ripping," particularly with any pulse asymmetry or hemodynamic instability, should be treated as a possible vascular emergency rather than a mechanical low back complaint.

Gastrointestinal and Genitourinary Review

GI and GU systems are common sources of visceral pain that mimics thoracolumbar and pelvic NMS complaints:

• Abdominal pain, changes in bowel habits, blood in stool -- screen for inflammatory bowel disease (which also clusters with inflammatory spondyloarthropathy), gastrointestinal bleeding, or malignancy
• Flank pain radiating to the groin, hematuria -- classic for renal colic (kidney stone), which can mimic acute low back or flank pain
• Dysuria, urinary frequency, urinary retention -- urinary tract infection or prostatic disease; retention combined with neurological findings raises concern for cauda equina
• Pelvic pain, abnormal vaginal bleeding (in female patients) -- gynecologic causes of low back and pelvic pain, including ectopic pregnancy and pelvic inflammatory disease, both of which require urgent referral
• Epigastric pain radiating to the back -- pancreatitis or peptic ulcer disease can present as thoracolumbar back pain

Psychiatric Review

Psychiatric ROS items -- mood, anxiety, sleep disturbance, appetite change, and any history of self-harm ideation -- are relevant both because depression and anxiety are common comorbidities that amplify chronic pain (overlapping with the yellow flags covered in personal and social history) and because unrecognized psychiatric symptoms can present with somatic complaints. A positive finding does not exclude an NMS diagnosis, but it should be documented and may warrant co-management.

Synthesizing ROS Findings on Part III

Part III case vignettes typically embed one or two ROS findings that are easy to overlook if you focus only on the chief complaint. The tested skill is pattern recognition: identifying that a specific combination of symptoms (for example, saddle anesthesia plus new urinary retention plus bilateral leg weakness) represents an emergent red-flag cluster rather than an isolated, incidental finding, and responding with appropriate urgency -- immediate referral rather than continued conservative management or additional non-urgent testing.