Showing posts with label ROS. Show all posts
Showing posts with label ROS. Show all posts

Sunday, January 27, 2019

Additional Work On The Review of Systems for Psychiatrists





My post on the review of systems for psychiatrists has had a lot of activity lately so I decided to post my latest update that was designed more for patient completion.  The original goal was to have an ROS that can be used like the one you get when you check in at an internist or surgeon's office.  In the last few years I have been checked in at various offices internists, orthopedic surgeons, ophthalmologists, urologist, and general surgeons) and have seen all of their ROS.  All are relatively brief with just a few symptoms.

The historical context of the ROS is that is seems to have migrated from the physicians exam to the waiting room.  To a skeptic like me the driving force has been the invasion of real medical services by the business and managed care world. That means much less  time with a physician but at the same time requires the physician to document much more. A key piece of that documentation is whether a ROS has been done.  Doing the ROS allows for the physician to bill for a more comprehensive assessment.  Having a completed form by the patient allows incorporation into the note from that day which has essentially become a billing document. I think it is safe to say that has become the primary role of the ROS today.  You will still see your physician for 10 or 15 minutes and they will still ask you some ROS style questions, but they will probably not ask you about the symptoms you endorsed is the waiting room. At least they never asked me.

The traditional role of the ROS is best described in my copy of DeGowin and DeGowin under System Review (Inventory of Systems) (p. 24):

"This is an outline for careful review of the history by inquiring for salient symptoms associated with each system or anatomic region.  Primarily it is a search from symptoms that may have escaped the taking of the present illness.  These symptoms should be memorized and their diagnostic significance learned. In practice, the answers are not written down except when positive. After the physician has fully mastered the outline, we suggest that he ask the questions when he is examining the part of the body to which they pertain...".

This is followed by a list of 20 symptom headline by body symptoms including the Mental status exam as item number 20.

Over the years there have been additional modifications for psychiatric specialists. The item in DeGowin and DeGowin for the mental status exam is really inadequate for psychiatric purposes so that is expanded and is on its own.

There was some ambivalence by members of the profession about the degree of medical care and knowledge required at one point in time.  This led to an expanded "psychiatric review of systems" in some circles that basically looked at symptoms of all of the major categories of psychiatric disorders and counted that as the ROS.  It was modified in some standard interviews that were even used in research.

My methods have always been medically based. That was what my mentors taught me and the patients I have treated over the years required. Psychiatrists can never lose sight of the fact that every medication they prescribe has the potential for causing serious medical illness and side effects. We can also never lose sight of the fact that practically every FDA package insert for a medication has medical contraindications, medical complications, and significant medication x underlying illness interactions. Finally, we deal with common medical morbidities like hypertension with severe long term side effects that cannot be ignored.

It is in that spirit that I offer the ROS.  It covers what I discuss with patients. It has evolved past the original System Review in that it is now common for patients to have detailed information about relevant diagnoses and diagnostic testing that they have had that is directly relevant to their psychiatric care. I have included that where relevant. 

I consider this document to be a starting point.  It is for educational purposes only and I am not recommending that you hand it to all of the patients in your waiting area.  I suggest modifying it for your needs and rewriting for your specific patient populations.  A downloadable Word version is available at the link below.  I dictate all of my evaluations and this form also facilitates that process if you need to list specific systems and positive and negative symptoms.  As an example, if the ROS is completely negative I will list the first three symptoms as negatives in my dictation.

Any feed back from medical psychiatrists would be greatly appreciated.


George Dawson, MD, DFAPA


References:

1: DeGowin EL,  DeGowin RL. Bedside Diagnostic Examination. 3rd Edition.  Macmillan Publishing Co. Inc; New York; 1976: p: 24-26.


Review of Systems As A Word Document 




Tuesday, October 31, 2017

Updated Review of Systems (ROS) for Medical Psychiatrists







The review of systems for psychiatry has changed significantly over the years.  Those changes were due to billing and coding decisions rather than clinical utility.  If you have been practicing long enough you have witnessed the transformation from a document very similar to what primary care physicians use, to one that is more focused on the sleep and appetite disturbances associated with psychiatric disorders. That results in a distinctly different ROS in psychiatry than the rest of medicine.  That puts medically based psychiatrists like myself at a disadvantage because the electronic health record (EHR) templates may not include the physical symptoms that I am most interested in and that requires more documentation. 

These changes are not unique to psychiatry.  Patients find themselves filling out checklists in many clinics that are essentially a surrogate ROS.  Something that your physician used to ask you in person and ask you to elaborate on is now a checklist.  In the modern EHR, the ROS is often just a series of checkboxes.  No elaboration required thank you.  The form that you fill out in the waiting area is incorporated into the physician's note often without reviewing it with the patient.  In some systems employing scribes or persons to do the documentation the scribe will type or dictate this form into the record. There is one additional point where the physician might read any ROS incorporated this way and that is during the read of the final note for signing.  That review is usually cursory because of time constraints - I doubt it is read with any regularity.  There is not enough time to read documentation 2 or 3 times as it is complied, transcribed, and entered into the EHR.

Another EHR strategy that is used from time to time is a statement: "A complete 10-point review of systems was done and it was negative."  Use of that statement depends on the billing, coding, and compliance staff and whether they think it meets the subjective standards of the day to demonstrate to somebody that the work was done. In my experience, unless you are interviewing a very healthy 20 or 30 year old it is unlikely that the ROS is completely negative.

The expanded ROS is more specific to medicine and it assumes that the physician is asking clarificatory questions.  I have found over the years that a very basic structured exercise like the ROS produces very different results depending on asking all of the questions, asking clarificatory questions, and pursuing obvious leads to other sets of questions depending on the patient response. Treating the ROS like it is a static series of yes or no questions is likely to produce the minimum amount of diagnostic information.

As an example consider the following example:

The ROS is being conducted on a 75 year old man.  He is being seen for insomnia.  In taking the medical history he says he was diagnosed with congestive heart failure 2 years earlier. He has impaired physical performance due to CHF and can only walk 100 feet and slowly climb a flight of stairs with great effort. On the ROS he endorses needing to prop himself up to breathe and occasionally wakes up suddenly at night due to shortness of breath.  Those symptoms and additional physical exam findings suggest that CHF is the problem rather than insomnia and the treatment needs to change accordingly. 

A more common example:

The ROS is being conducted on a 50 year old man.  He denies any cardiac or pulmonary symptoms and is only taking an 81 mg aspirin in addition to two different antidepressants. He has a 30 year history of smoking a pack a day of cigarettes.  The interviewer asks: "Have you ever had stress test?"  The patient states he does not know what that is. "You walk on a treadmill and they keep increasing the grade until you have to stop".  The patient replies that he took the test and the Cardiologist came in and sprayed something into his mouth. "Do you think that was nitroglycerin spray?" The patient states that it was and he had an immediate angiography and stent placement. 

Both examples illustrate that the ROS is dynamic and not static.  Filling it out in the waiting room may seem to be efficient, but the amount of information obtained in that setting is likely to be low relative to real medical problems that exist.  The probability of increased information from a more dynamic ROS increases with the age of the patient due to accumulated medical problems with age.

In addition to the list of symptoms in the ROS, additional heuristics at the level of pathological mechanisms can be considered to hone in on a specific syndrome.  The following table illustrates two of them.  For example, the General category in the ROS generally implies some kind of infectious, metabolic or endocrine condition - but it is not enough to make an actual diagnosis without further delineation. ROS categories are supposed to roughly correlate with body systems rather than pathological mechanisms, but many of the symptoms do not have a definable body system.


VINDICATE


VITAMIN D


V – Vascular

I – Inflammatory

N – Neoplastic

D – Degenerative / Deficiency

I – Idiopathic, Intoxication

C – Congenital

A – Autoimmune / Allergic

T – Traumatic

E –  Endocrine



V – Vascular

I – Inflammatory

T – Trauma

A –  Autoimmune

M –  Metabolic

I – Iatrogenic

N –  Neoplasm

D -  Degenerative


If I think the patient has a flu-like illness I ask about specific symptoms of flu-like illness. In addition to fatigue, weight change, fever, chills I might ask about - malaise, cough, rhinorrhea, nasal, congestion headache, sore throat, myalgias, chills, and sneezing.  Positives on several of these symptoms greatly increases the likelihood of a diagnosis of a flu-like illness.  Asking those questions occurs when an infectious etiology is suspected.

The typical review of systems that I used for years is printed below with red highlights for additional points that I ask if there are any markers in the initial history that suggests that they might be positive.  For example, if I am seeing a 50 year old with a long history of stimulant use, on three different antihypertensives and an anti-arrhythmic medication I will generally ask all of the cardiopulmonary symptoms and the additional questions about cardiac testing imaging and diagnoses.  For example: "You mentioned that you have never had a heart attack or a stroke, but has any doctor every told  you that you had cardiomyopathy or a thickened wall of the heart? Do you remember where all of that testing occurred?"




Review of Systems

General:  fatigue, weight change, fever, chills, night sweats

Endocrine: hot or cold intolerance, thyroid problems, hx of neck irradiation

HEENT: decreased visual acuity, hearing loss, tinnitus, vertigo, epistaxis, hoarseness or voice change, sinus/nasal infection or discharge, ear pain, history of ear infections, decreased auditory acuity

Pulmonary: dyspnea, cough, sputum production, chest pain or tightness, hemoptysis, asthma, bronchitis, emphysema, hx pneumonia, hx TB, hx positive/negative PPD, smoking hx
polysomnography, CPAP, APAP, BiPAP, nightmares, night terrors, parasomnia

Cardiovascular: chest pain, palpitations, tachycardia, syncope, edema, orthopnea, paroxysmal nocturnal dyspnea, claudication, phlebitis, hypertension, hx rheumatic heart disease, family hx heart disease
stress test, echocardiogram, angiography, stent placement, congestive heart failure, cardiac ablation, cardiac event monitoring, tilt table testing

Gastrointestinal:  nausea, vomiting, hematemesis, melena, dysphagia, indigestion, heartburn, abdominal pain, abdominal swelling, jaundice, hx hepatitis, hematochezia, diarrhea, constipation, hernia, hemorrhoids, peptic ulcer disease, gallbladder disease, pancreatitis, GI surgery
esophagogastroduodenoscopy, colonscopy, hepatic ultrasound, pancreatitis

Genitourinary: urinary frequency, urgency, dysuria, nocturia, hematuria, hx kidney stones, flank pain, hx STD, genital lesions, testicular mass or pain, sexual dysfunction
Hx acute renal failure

Gynecological: menarche, menopause, last menstrual period, description of menstrual periods, pelvic pain, vaginal discharge or bleeding, sexual dysfunction, breast mass, breast discharge, last breast exam, last mammogram
pregnancy history, hx pre-eclampsia or eclampsia

Skin: mole, other lesion, pruritus, rash, bruises, contusions, lacerations, burns, hx skin cancer

Hematopoietic: excessive bleeding, hx anemia, family history of disorder, lymphadenopathy

Neurological: headaches, migraines, ataxia, incoordination, vertigo, gait problems, falls, loss of consciousness, seizures, head injury, skull fracture, focal weakness, focal sensory change, hx stroke, micropsia, macropsia, metamorphopsia, chronic pain
Brain imaging, EEGs, coma, encephalitis, meningitis, chronic fatigue syndrome, movement disorders

Musculoskeletal:  joint pain, joint stiffness, joint swelling, muscle cramps, muscle pain, muscle wasting, hx fractures
Gout, Lyme Disease, fibromyalgia, rheumatic diseases, treatment by rheumatologist

Allergic/Immunologic: hay fever, rhinitis, seasonal symptoms
Allergy testing, specific allergens, immunotherapy


These are techniques that I have found useful over the years.  In psychiatry, the ROS is useful because I frequently have gotten past the medical history section and inquired about all major surgical and medical diagnoses from the past and the result is surprisingly thin.  More specific prompting about the diagnoses and which physicians the patient has seen in the past can produce much more information in an interview setting.  For psychiatric purposes, the ROS is also included in follow up visits and it seems necessary.  I find it useful for documenting intercurrent illnesses and medication side effects.  

Each class of psychiatric medications has their own relevant ROS that can be recalled with practice.  I might try to type those out at some point in time - but not tonight.  My main point here is that the ROS does have a function above and beyond the psychiatric history for psychiatrists.  People tend to view it as a difference necessary for one billing code or another.

I see it as an opportunity to figure out what is really going on medically with my patient and possibly diagnose another illness. It is also necessary to know that the patient does not have an underlying medical condition or treatment for that condition that contraindicates or necessitates closer monitoring of the proposed psychiatric treatment.


George Dawson, MD, DFAPA


ROS Files:  You can download the ROS files used for this post at the following links as Word documents.  Any suggestions for further modification appreciated:

ROS modified 

ROS standard



Additional Fact: 

A poster on Twitter [Alasdair Forrest @alasdairforrest] let me know that the ROS in the UK is called "systemic enquiry".






Tuesday, March 15, 2016

Baseball Caps, Wrap-Around Shades, and Sunglass Theory



I saw Erik van Kuijk MD, PhD present a lecture on macular degeneration at the Minnesota Academy of Medicine a couple of weeks ago.  He is an international expert in the subject and thoroughly reviewed the epidemiology,  basic science and current treatment of the disorder.  He described the risk factors including age (>60 years), smoking (doubles the risk), dietary factors (antioxidants) and sun exposure.  He  suggested the best barrier methods for sun exposure included baseball caps and wrap-around sunglasses.  At that point during the lecture, I had a brief episode of free association about that remark and thought about the sunglasses issue.   Within a few minutes I thought about sunglasses and their multiple roles in society.

To some sunglasses are a projective test.  I recall a college professor who seemed eager to tell anyone who would listen that men who had beards and sunglasses "had something to hide."  I had both, but could have told him that (being an introvert) of course I had something to hide, but it really had nothing to do with the beard and sunglasses.  Sunglasses can have special meaning with some psychiatric disorders that tend to magnify ordinary thoughts like - "These sunglasses make me look like an alien.  I might want to look like an alien."  You don't have to have a psychiatric disorder to have that thought.  Eye contact and facial expression depends a lot on the eyes and there are some people who realize this and do not want to expose that channel of communication.  On inpatient psychiatric units sunglasses are usually forbidden and rationales vary from place to place.  There are typically other patients and staff who are intimidated by people wearing sunglasses.  I was in a meeting at one point where one of the participants asked a late arrival about sunglasses because they were "freaking her out".  There are a couple of books out there that look at the social meaning of sunglasses both in terms of social behavior and fashion.  The scope of these books is discussed in the popular press largely in terms of why people with sunglasses may be more attractive.  The medical literature has surprisingly little to say about these factors. Indirectly there has been some work on facial symmetry as an attractive feature, and speculation that in some cases sunglasses give the appearance of greater facial symmetry.

As a cyclist, sunglasses have a prominent place in cycling literature.  Coaches typically advise eye protection for a number of reasons, but the best articulated one is to reduce fatigue.  If you are training and cycling tens to hundreds of miles per day, in most places you are going to be cycling into the sun at some point.  Without sunglasses there is a reflexive squint that eventually spreads to facial, neck, shoulder, back and chest muscles.  It would not surprise me that this also results in increased grip tension on the handlebars and that can increase blood pressure.  All of that muscle contraction leads to increased fatigue and decreased efficiency.  These factors probably explain why so many professional cyclists have shades and that they are some of the best designed wraparounds on the market.  Epidemiological studies also show that total sun exposure is a risk factor for macular degeneration and skin cancer.  That places certain occupations and recreational pastimes at higher risk.  A sampling of beach goers in Spain showed that there was no correlation between the subjects who sustained sunburns and whether they used adequate skin or eye protection.

Eye protection to prevent cataracts and macular degeneration is the most important application of sunglasses.  Ultraviolet light is to toxic factor and a recent review shows correlations with a significant number of eye diseases including eyelid malignancies, cataracts, photokeratitis, pterygium, and more limited data for other eye diseases (7).  As the eye ages, natural changes make it more susceptible to damage from UV light.  The literature from the National Eye Institute emphasizes that avoiding smoking, exercising regularly, blood pressure control, maintaining a low cholesterol, and eating a diet high in antioxidants and fish are the best preventive measures.  Sunglasses are not listed, but they were factored into the lecture I attended and many research articles. The dietary recommendations are based on trials of nutritional supplements used in the Age Related Eye Disease Study (AREDS-1 and AREDS-2).  In these studies, patients were recruited with early macular degeneration and were followed for progressive visual loss.  The formulation decreased the rate of progression of the eye disease.  The formulation in AREDS-2 consisted of lutein, xeaxanthin, Vitamin C, Vitamin E, zinc, and copper.  

The photobiology of light hitting the retina and macula is important in the development of macular degeneration.  The UV spectrum is typically broken up into UVA (320-400 nm), UVB (280-320 nm), and UVC (< 280 nm).  Only the first two are important since UVC is blocked by the ozone layer.  UVA has the deepest skin penetration and has been shown to generate reactive oxygen species (ROS) like singlet oxygen and hydrogen peroxide.(8)  Peroxiredoxins may be a significant defense against free radicals cause by UV light hitting eye structures.  Peroxiredoxin-3 (Prdx-3) is in the retina and lens of the eye.  In the  retina it is highly expressed in areas where there is high mitochondrial density.  The chemistry of lutein and xeaxanthin and their proposed role in preventing damage is interesting.  Both are 40 carbon conjugated compounds.  They absorb light at the 400 -500 nm range just outside of UV.  One of the ways that UV causes damage is by creating reactive oxygen species (ROS) when it hits susceptible structures in tissue.  The eye becomes more susceptible to UV damage as the chemical composition of chromophores in the eye change with aging.  As UV light hits phototoxic chromophores in the eye producing free radicals and singlet oxygen.  That in turn leads to photooxidation and damage to the eye.  Lutein and zeaxanthin act by quenching these ROS (11).  

Lutein
Zeaxanthin

What are the implications for psychiatrists in all of this?  The first is smoking cessation.  Smoking is a public health problem on its own and nicotine exposure is probably a gateway to further drug use with recent convincing work done on the epigenetic mechanism.  Macular degeneration is just another reason to advise people to not smoke.  The healthy diet and exercise proposed here for ophthalmology patients is another way of saying, avoid obesity and the metabolic syndrome.  Psychiatrists need to be giving their patients the same advice about diet and exercise.  Metabolic syndrome is a significant comorbidity, precursor, and iatrogenic complication of mental illness.  Some theorists have suggested that ROS produced in metabolic syndrome is a reason for the numerous complications.  Another potential research area is whether or not any current medications prescribed by psychiatrists increase the likelihood of cataracts, macular degeneration, or directly affect some of the phototoxic mechanisms that can occur in the eye.  I can recall that as a medical student we emphasized eye exams on psychiatric patients and there was a brief emphasis again when quetiapine was initially marketed, but not much evidence since.  In those days we were concerned about stellate cataracts and retinal hyperpigmentation caused by phenothiazines.  With the institutionalized deterioration in the quality of psychiatric care, this is another area for re-emphasis.  Every practicing psychiatrist needs to be aware of these mechanisms and at the minimum make recommendations for eye care, especially in aging patients.

The ophthalmology lecture was a good reminder that some disease mechanisms like oxidation can cut across several clinical specialties.  This provides a good opportunity for clinical psychiatrists to follow patients closely and potentially make more of a difference in their lives.


George Dawson, MD, DLFAPA


Normal Retina



References:

1:  Schick T, Ersoy L, Lechanteur YT, Saksens NT, Hoyng CB, den Hollander AI, Kirchhof B, Fauser S. HISTORY OF SUNLIGHT EXPOSURE IS A RISK FACTOR FOR AGE-RELATED MACULAR DEGENERATION. Retina. 2015 Oct 5. [Epub ahead of print] PubMed PMID: 26441265.

2:  Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol. 2014 Apr;34(2):383-400. doi: 10.1007/s10792-013-9791-x. Epub 2013 May 31. Review. PubMed PMID: 23722672.

3:  Roberts JE. Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye Contact Lens. 2011 Jul;37(4):246-9. doi: 10.1097/ICL.0b013e31821cbcc9. Review. PubMed PMID: 21617534. 

4: Sommerburg O, Keunen JE, Bird AC, van Kuijk FJ. Fruits and vegetables that are sources for lutein and zeaxanthin: the macular pigment in human eyes. Br J Ophthalmol. 1998 Aug;82(8):907-10. PubMed PMID: 9828775; PubMed Central PMCID: PMC1722697.

6:  National Eye Institute (NEI) Age-Related Macular Degeneration.

7:  Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol. 2014 Apr;34(2):383-400. doi: 10.1007/s10792-013-9791-x. Epub 2013 May 31. Review. PubMed PMID: 23722672.

8: Joan E. Roberts and Jessica Dennison, “The Photobiology of Lutein and Zeaxanthin in the Eye,” Journal of Ophthalmology, vol. 2015, Article ID 687173, 8 pages, 2015. doi:10.1155/2015/687173

9:  Szabo KE, Gutowski NJ, Holley JE, Littlechild JA, Winyard PG.  Redox control in human disease with a special emphasis on the peroxidation-based antioxidant system. in Redox Signaling and Regulation in Biology and Medicine.  Claud Jacob and Paul G. Winyard (eds); Wiley-VCH; Weinheim; 2009; 409-431.

10: Poh S, Mohamed Abdul RB, Lamoureux EL, Wong TY, Sabanayagam C. Metabolic syndrome and eye diseases. Diabetes Res Clin Pract. 2016 Jan 15. pii: S0168-8227(16)00065-6. doi: 10.1016/j.diabres.2016.01.016. [Epub ahead of print] Review. PubMed PMID: 26838669.

11:  Terao J, Minami Y, Bando N. Singlet molecular oxygen-quenching activity of carotenoids: relevance to protection of the skin from photoaging. Journal of Clinical Biochemistry and Nutrition. 2011;48(1):57-62. doi:10.3164/jcbn.11-008FR.



Attribution:

Chemical structures were downloaded directly from PubChem accessed on March 14, 2016.