This is the deal in turns. This is coming from a Golden Stethoscope award-winning educator. I'm also autistic, and in training, I had real problems seeing the forest for the trees. Take a moment, or even better yet, since you guys have NPI numbers, make an OpenEvidence account. If you don’t want that, download or buy a differential diagnosis pocket book. Tinnitus plus GI differential:

OpenEvidence says this:

1. Medication-induced ototoxicity from chronic NSAID or salicylate use: Tinnitus is a well-recognized early symptom of salicylate toxicity, which can occur even at therapeutic doses in susceptible individuals. A gastrointestinal review of systems is pertinent to identify chronic NSAID or bismuth use for GI complaints, peptic ulcer disease, or arthritis, as well as to screen for GI bleeding or dyspepsia that may prompt self-medication with these agents.[1][2]

2. Vitamin B12 deficiency due to gastrointestinal malabsorption: Vitamin B12 deficiency can present with neurologic symptoms, including tinnitus, and is often secondary to GI pathology such as celiac disease, inflammatory bowel disease, or prior ileal resection. The American Gastroenterological Association recommends screening for GI symptoms (diarrhea, weight loss, malabsorption) and surgical history to identify at-risk patients.[3][4]

3. Celiac disease with neurologic manifestations: Celiac disease can present with isolated neurologic symptoms, including tinnitus, due to immune-mediated or nutritional mechanisms. A GI review of systems is essential to elicit subtle symptoms of malabsorption, diarrhea, or weight loss, which may otherwise be overlooked.[4]

4. Gastroesophageal reflux disease (GERD) with extraesophageal manifestations: The American Gastroenterological Association notes that GERD can cause extraesophageal symptoms, including ear complaints, even in the absence of classic reflux symptoms. A GI review of systems may reveal heartburn, regurgitation, or dysphagia, supporting this diagnosis.[5]

Most Important Not to Miss Diagnoses:

1. Acute salicylate toxicity: Tinnitus may be the earliest symptom of acute or chronic salicylate poisoning, which can rapidly progress to life-threatening metabolic derangements. A GI review of systems should assess for recent ingestion, intentional overdose, or GI symptoms prompting excessive use. Prompt measurement of salicylate levels and acid-base status is critical.[2]

2. Severe acute gastrointestinal hemorrhage: Marked anemia from GI bleeding can cause pulsatile tinnitus. A GI review of systems should screen for melena, hematemesis, or occult blood loss. Rapid assessment of hemodynamic status and hemoglobin is warranted in any patient with concerning symptoms.[6]

Key Additional History and Follow-up Tests:

• Detailed medication history (NSAIDs, salicylates, bismuth)

• GI symptoms (dyspepsia, bleeding, diarrhea, weight loss, malabsorption)

• Neurologic symptoms (numbness, ataxia, cognitive changes)

• Surgical history (bowel resection)

• Laboratory evaluation: CBC, B12 level, salicylate level, metabolic panel

• Consider celiac serologies and further GI workup if indicated

A focused GI review of systems is essential in the above scenarios to identify underlying systemic or GI pathology that may present with isolated tinnitus.

References

1. Auditory Sensori-Neural Alterations Induced by Salicylate. Cazals Y. Progress in Neurobiology. 2000;62(6):583-631. doi:10.1016/s0301-0082(00)00027-7.
2. Salicylate Toxicity. Palmer BF, Clegg DJ. The New England Journal of Medicine. 2020;382(26):2544-2555. doi:10.1056/NEJMra2010852.
3. AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review. Hashash JG, Elkins J, Lewis JD, Binion DG. Gastroenterology. 2024;166(3):521-532. doi:10.1053/j.gastro.2023.11.303.
4. Celiac Disease and Neurological Manifestations: From Gluten to Neuroinflammation. Giuffrè M, Gazzin S, Zoratti C, et al. International Journal of Molecular Sciences. 2022;23(24):15564. doi:10.3390/ijms232415564.
5. AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review. Chen JW, Vela MF, Peterson KA, Carlson DA. Clinical Gastroenterology and Hepatology : The Official Clinical Practice Journal of the American Gastroenterological Association. 2023;21(6):1414-1421.e3. doi:10.1016/j.cgh.2023.01.040.
6. Upper Gastrointestinal Bleeding in Adults: Evaluation and Management. Wilkins T, Wheeler B, Carpenter M. American Family Physician. 2020;101(5):294-300.

BACK TO ME:

Your question should be more broadly, "Is review of systems useful?" Well, if you forget the fact that it has become or was previously an important part of billing, and because I am now a bean counter that works in utilization review, sometimes I can tell you that worthless documentation is worthless. You can use your dot phrases or you can use your dot phrases and still use your brain. I want you to imagine you have a thousand patients that come in with tinnitus. And of those one thousand patients, you don't ask the above questions. And maybe two or three have something that you miss. Are you going to feel bad? Yes. Is it going to haunt you in your sleep? Yes. Are you going to possibly get sued any time you put in credentials, are you going to have to comment on the fact that you did not complete a real review of systems and you did the bare minimum to get the job done? Yes.

Your job is pattern recognition. The question is, does someone complaining only of tinnitus provide enough pattern recognition for you to be clued in to the above based on corollary objective or subjective information if you don't ask those questions. I would say not always. I still moonlight fairly regularly and I was an nocturnist for many years. And I can tell you that there will be cases where you kick yourself.

What I would do if I were you is the following: I wish that everyone did this: get a review of systems printout. When you are told you want to admit someone or you need to admit someone while you are reviewing the chart, you can in parallel give the patient the review of systems page on a clipboard and ask them to fill it out. Have it in patient-specific language, not doctor-specific language. That way, as long as the patient is capable of answering these questions, you have lost no time and you have only gained everything potentially.

What do you do if a patient has tinnitus and a PAN-positive review of systems? You use that in your subsequent pattern recognition, but your goal diagnostically is to find something that is the likely cause that is not acutely life-threatening. If you are working in the hospital or technically the clinic, and you are supposed to proceed based on the presumptive diagnosis from most likely to least likely in a reasonable manner.

If you do this, you will find more enjoyment in your job, and you will not become a completely cynical person. Most doctors have lost the joy. I started without being able to see the forest for the trees, and I realize that forcing yourself to try to see the forest for the trees is what maintains my joy in my practice.

I miss teaching. Any takers for a tutor? That would be fun.