Importance of Review of Systems (Ros) Nursing Journal

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JAMA Otolaryngol Caput Neck Surg. 2017 Sep; 143(ix): 870–875.

Association Between Patient Review of Systems Score and Somatization

Tyler Stephen Okland

¹Department of Otolaryngology, Academy of Colorado School of Medicine, Aurora

Joseph Robert Gonzalez

¹Department of Otolaryngology, University of Colorado School of Medicine, Aurora

Alexander Thomas Ferber

²Medical Scientist Training Programme, Section of Physiology & Biophysics, Academy of Colorado School of Medicine, Aurora

Scott Edward Isle of mann

¹Department of Otolaryngology, Academy of Colorado Schoolhouse of Medicine, Aurora

^threeDivision of Otolaryngology, Denver Health Medical Heart, Denver

Received 2016 Jul xx; Accustomed 2017 Apr 7.

Supplementary Materials

Supplement: eAppendix. The 69-Indicate Review of Systems Class

GUID: 8F9826A2-D613-4662-A029-B366F55791CC

Key Points

Question

What is the relationship between medically unexplained symptoms, psychiatric illness, and the number of positive responses on a medical review of systems in otolaryngology patients?

Findings

In this retrospective medical record review that included 605 adults, the number of positive responses to a 69-detail standardized review of systems was significantly higher in patients with medically unexplained symptoms, a history of psychiatric diagnoses, and symptoms associated with somatization (dizziness, globus sensation, and tinnitus).

Meaning

The review of systems may exist useful in identifying somatization as an underlying source of the symptoms in otolaryngology patients.

Abstract

Importance

Somatization is a condition in which psychological distress is manifested by medically unexplained symptoms, and it is prevalent in all medical specialties, including otolaryngology. Recognition of somatization can exist hard, and in that location are express methods available.

Objectives

To make up one's mind whether patients with somatization respond differently to the review of systems (ROS) portion of the patient interview and whether the ROS can be used to identify patients with somatization.

Design, Setting, and Participants

A retrospective review of medical records of 2120 sequent consultations of English language- or Castilian-speaking patients aged 18 to 89 years who presented to the otolaryngology clinic from Jan i, 2014, to Nov 10, 2015, was conducted to compare how the ROS of patients with primary complaints associated with somatization (group B: globus sensation, dizziness, and tinnitus) differs from those with symptoms more oft associated with objective findings (group A: nasal obstacle, hoarseness, and hearing loss); a total of 605 patients were included. Objective clinical findings after concrete examination and related testing were reviewed and classified as either pregnant, marginal, or absent-minded. Current or past psychiatric comorbidities were also examined.

Main Outcomes and Measures

Number of affirmative responses on a standardized, 69-point ROS was recorded as a ROS score (ROSS). Objective clinical findings, symptoms, and psychiatric comorbidities were recorded.

Results

Of the 605 patients included in the analysis, 346 (57.2%) were women, and the mean (SD) age was 51.6 (15.7) years. Among patients with medically unexplained symptoms (median, 11; range, 0-39), the ROSS was higher compared with those with objective clinical findings (median, 6; range, 0-31) (median difference, 4; 95% CI, iii to vi). Group A (hoarseness, nasal obstruction, and hearing loss: median ROSS, 6, range, 0-41) exhibited lower ROSS than group B (dizziness, globus awareness, and tinnitus: median ROSS, 9; range, 0-39) (median difference, −2; 95% CI −three to −1). Psychiatric comorbidity (median, ten; range, 0-41) was associated with higher ROSS than patients without psychiatric comorbidity (median, 5.five; range, 0 to 36) (median difference, 5; 95% CI, iii to 6).

Conclusions and Relevance

The manner in which patients respond to a standardized ROS differs in those with medically unexplained symptoms and in those with psychiatric disease. The ROS offers information beyond the actual systems review, and may be useful in the identification of somatization.

Introduction

Medically unexplained symptoms (MUS) are somatic symptoms for which a pathophysiologic mechanism cannot exist identified. Patients with MUS are frequent utilizers of the health intendance system and account for upward to one-third of all master care evaluations and 21% of specialty consultations. This level of use represents a significant burden on the health intendance organization, including otolaryngology. A customs survey conducted by Kirmayer et al reported that 10.5% of participants had an unexplained symptom in the prior year. Ear, olfactory organ, and throat symptoms were the 3rd nearly common MUS among those surveyed. Otolaryngologists are oftentimes consulted for symptoms that take limited physical examination findings. Some of these symptoms remain unexplained later on further testing and are challenging to relieve. For instance, while a report of hearing loss will often be corroborated with findings on audiologic testing, objective abnormalities in those presenting with dizziness or tinnitus are less normally found.

In that location is, however, a articulate connection betwixt these types of symptoms and psychiatric disease. Patients reporting tinnitus or dizziness are more than likely than others to experience anxiety or depression. Patients presenting with globus sensation (another symptom oft associated with few objective findings) are more likely to have a diagnosis of major depression, generalized anxiety disorder, somatization disorder, posttraumatic stress disorder, and drug abuse. When a MUS is determined to be a manifestation of underlying psychological distress, it is called somatization.

Recognition of somatization can provide significant benefit for patients with MUS and prevent unnecessary or invasive testing. Even with extensive workups, these patients often perceive that their physicians have given insufficient medical explanation or handling options, and this ambiguity perpetuates a bicycle of distress and worsening of the somatic symptom. Prolonged somatization may event in debilitating symptoms refractory to treatment. Accumulating evidence suggests early on recognition and intervention with cognitive behavioral handling regimens can atomic number 82 to meaning improvement or remission.

Early recognition also benefits the wellness care system. Patients with somatization disproportionately utilize medical services and accept more than emergency, primary care, mental wellness, and specialty visits; more outpatient procedures; and more infirmary admissions. The annual health intendance costs attributed to somatization in the United States is an estimated $256 billion.

Unfortunately, recognition of somatization can be challenging for the clinician. There are limited tools available to assist in the diagnosis. Some sources advocate for identifying risk factors with screening questionnaires or identifying characteristic patterns of care utilization, just these methods require resource and detailed medical records review that are non always viable in a specialty clinic environment.

I common conventionalities amid physicians is that patients with somatization respond differently during a review of systems (ROS). Because these patients often present with wide-ranging symptoms affecting multiple organ systems, they may manifest a "pan-positive" ROS during the patient interview. An increased number of reported symptoms on the ROS has been shown to correlate with characteristics of borderline personality disorder. Information technology has also been shown to have predictive value when delineating epileptic from psychogenic nonepileptic seizures. In a study of patients with gastrointestinal symptoms, an increased number of symptoms reported on the ROS was constitute to exist sensitive and specific in indicating which patients were eventually deemed to have a functional gastrointestinal disorder.

We hypothesized that the manner in which patients reply to a ROS could be useful in identifying somatization in a general otolaryngology practice. Specifically, we sought to understand how responses to a standardized ROS would differ in patients with symptoms associated with somatization (globus sensation, dizziness, and tinnitus) compared with those with symptoms more often associated with objective findings (nasal obstruction, hoarseness, and hearing loss). In addition, nosotros investigated how the number of positive responses during a ROS related to subsequent objective findings. Current or past psychiatric comorbidities were also examined.

Methods

Study Design

We performed a retrospective medical records review of 2120 consecutive outpatient consultations at a community otolaryngology clinic seen from January 1, 2014, to Nov ten, 2015. Nosotros included patients who presented with one of 6 predetermined chief complaints: hearing loss, hoarseness, and nasal obstruction (group A), and globus sensation, tinnitus, and dizziness (group B). Only English- or Spanish-speaking patients, aged 18 to 89 years, seen by 1 of iii attending otolaryngologists (including SEM) were included in the study. In full, the records of 605 patients were examined, 346 (57.ii%) of whom were women, and 259 (42.8%) were men. All information were collected under the approval of Colorado Multiple Institutional Review Board and entered into a database for statistical analysis; data were deidentified.

A detailed medical records review of the initial consultation and all subsequent or related testing was performed. All patients had completed a standardized 69-betoken ROS questionnaire (eAppendix in the Supplement). This form was available in English and Castilian. Nosotros recorded the number of affirmative responses as a ROS score (ROSS). The patient records were as well examined for history of psychiatric affliction. The medical records review was completed in a systematic fashion to minimize reviewer bias with conquering of information in the following order: main complaint, clinical findings, ROS analysis, and presence of psychiatric comorbidities. The decision of clinically meaning findings was divers prior to medical records review equally presence of any clearly documented physical test (including endoscopy), audiometry, or imaging study abnormalities that were causally related to the symptoms by the treating physician. Marginal findings were defined equally nonspecific physical examination results or findings documented as very mild or minor. Medically unexplained symptoms were defined equally those in which no related objective findings were found in initial or subsequent evaluations.

Statistical Assay

For investigation of trends, a cluster analysis was used to split patients into groups formed by the distribution of ROSS. A two-pace cluster analysis was performed, revealing that the data fit into 4 groupings: 0 to 3, iv to 7, 8 to 13, and higher than 14. The quality of these cluster groupings was confirmed with a goodness-of-fit and pseudo R ⁱⁱ analyses. Statistical analysis was conducted in MATLAB (The MathWorks Inc). The ROSS information were used to compare diverse groups; median differences and 95% CIs were calculated.

Results

A total of 605 patients were included, with 387 comprising group A (nasal obstruction [north = 111], hoarseness [n = 74], and hearing loss [due north = 202]), and 218 in grouping B (globus sensation [n = 54], dizziness [north = 83], and tinnitus [n = 81]). The hateful (SD) historic period of all participants was 51.six (15.7) years, with 346 women (57.2%) and 259 men (42.viii%). A total of 523 (86.four%) patients were English speaking, and 82 (13.6%) were Spanish speaking. There were no differences in age between group A (median, 53; range, xvi-ninety) and B (median, 54; range, nineteen-84) (median difference, −1 twelvemonth; 95% CI, −4 to two years). Grouping A had fewer women with 204 (52.7%) vs 142 (65.ane%) in grouping B. Of the 605 total patients, 95 (15.7%) had no objective findings in initial or subsequent evaluations that explained their presenting symptom. A full of 170 (28.i%) patients were found to have marginal objective findings that could explain their principal complaint. Three hundred forty (56.2%) patients presented with significant objective findings.

As expected, the ROSS data were not normally distributed (Effigy 1). A Spearman rank-lodge correlation test indicated that ROSS was non related to age (r _s = −0.016; 95% CI, −0.083 to 0.051). Median ROSS for patients presenting with significant findings was vi (range, 0-31) vs 11 (range, 0-39) for those with MUS (Figure iiA). Patients with significant findings exhibited a lower ROSS (median deviation, −4; 95% CI, −6 to −3). Median ROSS for patients in grouping A was 6 (range, 0-41) compared with 9 (range, 0-39) in group B (Figure 2B); median ROSS was lower for patients in group A (median difference, −2; 95% CI, −3 to −1). The prevalence of MUS was 7.v% in grouping A patients and thirty.1% in group B patients.

Distribution of Review of Systems Scores

Scores were not normally distributed.

Responses on the Review of Systems (ROS)

A, Positive responses on the ROS, comparing patients with significant clinical findings vs those with unexplained symptoms. B, Positive responses on ROS for grouping A (hearing loss, nasal obstruction, and hoarseness) and group B (tinnitus, dizziness, and globus awareness) patients. Both plots demonstrate differences in medians, with shaded areas representing 1st to 3rd quartiles and mistake bars representing information ranges.

An inverse relationship was constitute between the ROSS and the significance of clinical findings. Of patients who had a ROSS of 0 to 3, meaning objective findings were identified in 115 of 153 (75.2%); of those who had a ROSS of 4 to 7, significant objective findings were identified in 98 of 156 (62.viii%); of those who had a ROSS of eight to 13, significant objective findings were identified in 83 of 162 (51.2%); and of patients who had a ROSS of 14 or higher, significant objective findings were identified in 44 of 134 (32.8%) (Effigy 3A). Group A patients with no clinical findings had a median ROSS of 8 (nine for marginal findings and 5 for pregnant objective findings). Group B patients with no clinical findings had a median ROSS of 11 (eight for marginal findings and vi for meaning objective findings).

Clinical Findings vs Review of Systems Score (ROSS)

A, Clinical findings vs ROSS for all patients. Per centum of significant and marginal or absent findings for all patients grouped by ROSS. B and C, Percentage of significant and marginal or absent findings for group A and group B grouped by ROSS. Marginal findings and absent findings (MUS) had parallel and overlapping trends, so are presented together.

When only group A patients were examined, of those with a ROSS of 0 to 3, significant objective findings were identified in 96 (87.3%); of those with a ROSS of 4 to 7, significant objective findings were identified in 86 (77.5%); of those with a ROSS of eight to 13, meaning objective findings were identified in 63 (67.seven%); and of those with a ROSS of 14 or college, significant objective findings were identified in 38 (52.i%) (Figure 3B). When but group B patients were examined, of those with a ROSS of 0 to 3, significant objective findings were observed in 19 (44.two%); of those with a ROSS of 4 to 7, significant objective findings were observed in 12 (26.vii%); of those with a ROSS of 8 to thirteen, significant objective findings were observed in 20 (28.99%); and of those with a ROSS of 14 or higher, pregnant objective findings were observed in vi (ix.84%) (Effigy 3C). Overall, 233 (38.v%) patients included in this study had psychiatric comorbidity (163 [47.one%] women and 79 [27.0%] men).

The presence of psychiatric comorbidity was associated with an increased ROSS. The median ROSS was xi.5 for those with a history of depression (due north = 156), 12 for feet (due north = 72), 9 for fibromyalgia/chronic pain (north = 91), and 12 for posttraumatic stress disorder (n = four). This was in contrast to a median ROSS of v.five for patients with no psychiatric history. Analysis revealed a departure in ROSS scores betwixt patients with (median, x; range, 0-41) and without (median, five.5; range, 0-36) psychiatric disease, where patients with psychiatric disease exhibited higher a ROSS (median departure, five; 95% CI, 3 to half-dozen). This difference was present and in both groups A and B, although, of patients in group A, merely 31.2% possessed psychiatric comorbidity, compared with 51.4% in group B. In group A, patients with a psychiatric history were constitute to accept a greater median ROSS of ten (range, 0-41), compared with 5 (range, 0-36) in those without (median departure, 5; 95% CI, 3-6). Grouping B patients with psychiatric comorbidity were found to have a greater median ROSS of xi (range, 0-39), compared with 7 (range, 0-32) in those without (median deviation, 4; 95% CI, 2-6).

The prevalence of psychiatric affliction was directly related to ROSS (Effigy ivA). For patients in group A who reported 0 to 3, iv to 7, 8 to 13, and 14 or more than symptoms, the prevalence of psychiatric diagnoses was 16.4%, 24.iii%, 33.3%, and 61.6%, respectively. For patients in group B who reported 0 to 3, 4 to 7, 8 to 13, and 14 or more symptoms, the prevalence of psychiatric diagnoses was 37.two%, 35.6%, 55.1%, and 68.9%, respectively. In addition, a Spearman rank-social club correlation indicated a moderate positive clan between the number of psychiatric diagnoses and the ROSS seen in all patients (r _south = 0.3511; 95% CI, 0.291-0.408). Median ROSS for patients with no psychiatric diagnosis was 5.five; for those with 1 psychiatric diagnosis, 10; for 2 diagnoses, nine; and for 3 diagnoses, 22 (Figure 4B).

Review of Systems Score and Psychiatric Comorbidity

A, Prevalence of psychiatric diagnosis vs review of systems, grouped by review of systems score (ROSS). B, Median ROSS for all patients by the number of different psychiatric diagnoses nowadays in the medical tape. One patient with 4 psychiatric diagnoses (ROSS, 12) was included in the correlation assay but not shown in the figure.

Discussion

Somatization is an important miracle to recognize in otolaryngology. In addition to the associated health care costs, it can exist debilitating for patients. All-encompassing investigations into MUS can be counterproductive for the patient and pb to worsened symptoms. It is important that specialists be aware of somatization as a possible source of the symptoms and include it in their differential diagnosis. With this study, we investigated whether the ROS could exist helpful in identifying somatization in otolaryngology patients and to identify trends in regard to MUS or psychiatric illness. The chief complaints investigated were chosen based on the previous associations of somatization with dizziness, tinnitus, and globus sensation. As a comparison grouping, nosotros chose iii symptoms that we considered to have frequent objective findings in a similar patient population: nasal obstruction, hearing loss, and hoarseness. Within these chief complaints there was a xv.seven% rate of MUS (no objective findings on subsequent evaluation/testing). When the ROS responses were examined, they were establish to be different in patients with MUS. The number of positive responses was college than in those who had definite objective findings explaining their symptoms (Effigy 2A). These results support the notion that the ROS responses are different in patients with MUS. In our 2 cohorts, group A (nasal obstruction, hoarseness, and hearing loss) had fewer positive responses on the ROS compared with group B (globus sensation, dizziness, and tinnitus) (Effigy 2B). This finding suggests farther that the ROS may exist answered differently by patients with somatization. However, this variation could be confounded past differences in psychiatric comorbidity betwixt groups. There was a college charge per unit of psychiatric history in group B (112 [51.4%] vs 121 [31.3%] patients in grouping A). Our results revealed that psychiatric affliction had an upshot on the ROSS, which was higher in patients with psychiatric comorbidity and showed a tendency of increasing further with multiple psychiatric diagnoses (Figure fourB). This finding suggests that the ROS could potentially exist helpful in the evaluation of other psychiatric weather likewise. In our report, in that location was a much higher number of MUS in group B (18.81% vs iv.91% in grouping A), and in both groups there was an apparent inverse relationship between responses on the ROS and objective findings (Figure 3).

In patients with somatization, psychiatric distress manifests as MUS. Our assay showed an increase in positive responses on the ROS with psychiatric comorbidity and also with MUS. This finding suggests that patients with somatization will have a ROS that has more positive responses than those without.

There were MUS, psychiatric illness, and high ROSS present within all patient groups. Despite the trends observed, somatization may be nowadays in any clinical scenario and our results back up this understanding. This study and future work hopefully will aid otolaryngologists in the clinical evaluation of patients with MUS. When faced with MUS, a clinician should consider somatization in the differential diagnosis, particularly if the ROS has a high number of positive responses.

Limitations

There are several clear limitations of this study. None of the patients were formally evaluated for somatization at the time of their consultations, and so the actual incidence of somatization in the report population is unknown. Also, the patient population included was from a "safe-net" medical center, and the results may not be applicative in other populations. Our overall prevalence of psychiatric diagnoses was elevated at 38.eight%. In addition, this was a retrospective review of medical records that probable included inherent biases of the treating physicians. Patients with a multitude of symptoms on the ROS may have received a different style of evaluation and subsequent documentation. Prospective controlled studies would exist needed to validate any predictive value of ROS equally a diagnostic tool for somatization.

Conclusions

Medically unexplained symptoms and somatization are common to all medical fields, including otolaryngology. Identifying a somatic symptom as a manifestation of underlying psychiatric distress offers significant do good to patients as well every bit to the health care organisation. The manner in which patients reply to a standardized ROS differs in those with MUS and in those with psychiatric disease. Increasing positive responses on a patient'south ROS was associated with less objective bear witness of affliction. The ROS offers valuable data beyond the actual systems review and may be useful in the identification of somatization.

Notes

Supplement.

eAppendix. The 69-Bespeak Review of Systems Form

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710288/

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