A key tool in the physician’s arsenal is the review of systems, or ROS—a run-through of pertinent symptoms while taking a patient history. The ROS is essential for narrowing the differential diagnosis. To the novice clinical student, however, it can feel overwhelming. Medical students often first learn the ROS as I did—as a giant, inscrutable list of symptoms. This wiki entry should provide a taste. Over time, I whittled the list down to my personal preferences. It should be adjusted and clarified depending on the patient’s symptoms, but here’s the catch-all version:
Gen: denies headache/dizziness, syncope, seizures, fever/chills, night sweats, fatigue, weight change, appetite changes
HEENT: denies hearing/vision changes, runny nose, sore throat
CV: denies chest pain, palpitations, exercise intolerance
Pulm: denies cough, wheezing, shortness of breath
GI: denies nausea/vomiting, constipation/diarrhea, abdominal pain, stool changes
GU: denies urinary changes, discharge
Skin: denies skin changes, rashes
Neuro: denies numbness, weakness
It helps to be able to rattle off this 32-symptom list in your sleep. You don’t want to be caught tongue-tied, and you’ll need to jot it down into the electronic medical record from memory. As such, I wrestled with different approaches to memorizing these 32 symptoms. Options included the standard memory palace (using, say, my local movie theater as a palace), acronyms, or brute force plus spaced retrieval practice. Knowing that patient encounters would provide more than enough practice, the traditional memory palace technique felt unnecessary. Instead, I landed on the body palace, which maps nicely with the way the ROS is traditionally organized—by body system. I consider this approach a memory palace/brute force hybrid. Per the memory palace technique, I use spots on my own body as loci. However, I do not turn the information (eg, fever) into images. I simply use the body loci to organize the ROS into digestible chunks of 2-4 symptoms.
I’ll start by making the first locus the upper right part of my head (ie, where an antler might come off). I chunk the first four onto this locus: headache, dizziness, syncope, seizures (I sometimes drop the seizures). Headache fits the location, and the others are related. You can imagine a headache might make you dizzy, even pass out. I arbitrarily jump to the same point on the left side of my head for locus #2: fever, chills, night sweats. Again, these symptoms are related, and the location loosely fits; fever comes the brain. Now, I move down to my forehead for locus #3: fatigue, weight change, appetite change. This triad is cancer-related—cancer, the kind of thing that smacks you right in the forehead. Ten symptoms down. These three chunks were the most arbitrary, so it should be downhill from here.
I’ll move down to various spots on the face: the ears (hearing changes?), the eyes (vision changes?), the nose (runny nose?), the mouth (sore throat?).
Next, down to the heart: chest pain, palpitations, exercise intolerance. All cardiovascular symptoms. Similarly, the lungs: cough, wheezing, shortness of breath. And backing up deeper into the thorax, we reach the start of the gastrointestinal system, the esophagus: nausea, vomiting. Move down the GI system toward the belly: abdominal pain. Finally, coming out the other end: constipation, diarrhea, stool changes. Then, it’s easy enough to jump around to the front: urinary changes, discharge.
Nearly there. At this point, I’ve finished with the “loci.” It’s not terribly hard to remember the remaining two chunks, which are full-body. Skin: skin changes, rash. Neuro: weakness, numbness.
Done! At this point, I encourage you to mentally rehearse the list, à la retrieval practice. How many can you remember without looking? We started at the upper right head, then the left, then the forehead, then ears, etc. If you forget a few, take a peek and try again. Once you’ve nailed it, try actively recalling it again tomorrow, and then a few days later.
After meeting a patient and evaluating the chief complaint using OLD CARTS, I always run through this 32-symptom list. The body palace makes it relatively painless to rattle off. Have an alternative approach to learning the Review of Systems? Let us know in the comments below!
For a general recap of how we used memory techniques during our third year of medical school, see How Should Medical Students Use Memory Techniques In The Clinical Setting? [Video]