What should be included in the General section of a review of systems for a patient with a past medical history of chronic conditions such as diabetes, hypertension, or heart disease?

General Section of Review of Systems

The General section of the Review of Systems should systematically assess constitutional symptoms including fever, night sweats, unintentional weight changes, fatigue, and changes in functional capacity, with particular attention to how current weight compares to baseline and overall ability to perform activities of daily living. 1

Constitutional Symptoms to Document

Weight and Nutritional Status

• Document current weight compared to baseline weight, asking specifically about unintentional weight loss or gain over the past 3-6 months 1
• Assess dietary patterns and any changes in appetite 1
• For patients with chronic conditions, calculate and record BMI at each visit 1

Fever and Night Sweats

• Query about fever episodes, including frequency, duration, and associated symptoms 1
• Ask specifically about night sweats that require changing clothes or bedding 1
• These symptoms may indicate infection, malignancy, or inflammatory conditions requiring further evaluation 1

Fatigue and Energy Level

• Assess changes in energy level and fatigue patterns, including onset, duration, and impact on daily activities 1, 2
• Document whether fatigue is present at rest or only with exertion 2
• For patients with cardiovascular disease, decreased exercise tolerance is a critical finding 2

Functional Assessment

Activities of Daily Living

• Evaluate the patient's ability to perform routine and desired activities of daily living 1
• This includes basic self-care activities (bathing, dressing, eating) and instrumental activities (shopping, cooking, managing medications) 1
• For older adults with chronic conditions, functional performance assessment should be considered annually 1

Exercise Tolerance

• Document any decrease in exercise tolerance or ability to perform usual physical activities 2
• Ask about specific limitations: distance able to walk, flights of stairs tolerated, activities that cause shortness of breath 2

Social Determinants and Support Systems

Critical Social Factors

• Screen for food security, housing stability, transportation access, financial security, and community safety 1, 3
• These social determinants directly impact medication adherence, follow-up care, and disease management 1, 3
• Document existing social supports and identify surrogate decision makers 1

Substance Use History

• Obtain detailed history of alcohol consumption, categorizing as: none, ≤1 drink/week, 2-7 drinks/week, or ≥8 drinks/week 1
• Document any history of alcohol dependency or medical sequelae of alcohol use 1
• Ask about tobacco use, including current status and pack-year history 1, 4
• Query about illicit drug use, particularly cocaine, amphetamines, and injection drug use 1, 3

Mental Health Screening

Depression and Mood Changes

• Screen for depression by asking about changes in mood, libido, sleeping patterns, appetite, concentration, and memory 1
• Use validated screening tools for depression and anxiety 1, 4
• This is particularly important as depression prevalence is elevated in patients with chronic conditions 1

Stress and Trauma

• Assess for posttraumatic stress disorder and history of domestic violence 1
• Screen for current or past physical or sexual abuse 1

Medication and Treatment History

Current Medications

• Document all prescription medications, over-the-counter agents, herbal supplements, and nutritional supplements 1, 3
• Assess medication-taking behavior and adherence patterns 1, 3
• Record any medication intolerances or side effects 1
• For patients on metformin, document duration of use (relevant for vitamin B12 screening) 1

Alternative Therapies

• Ask about use of complementary and alternative medicine 1
• Document any "alternative therapies" that may impact conventional treatment 1

Technology and Self-Management

Health Technology Use

• Assess use of health apps, online education resources, and patient portals 1
• For patients with diabetes, review glucose monitoring results and data use 1
• Document use of any home monitoring devices (blood pressure monitors, scales, pulse oximeters) 1

Common Pitfalls to Avoid

• Do not assume patients will volunteer information about substance use, mental health symptoms, or social barriers—direct, specific questioning using neutral language is essential 1, 3
• Avoid focusing only on current symptoms while neglecting functional status—the ability to perform daily activities is a critical outcome measure 1
• Do not overlook social determinants of health—these factors profoundly impact disease management and outcomes in patients with chronic conditions 1, 3
• Never skip medication reconciliation—polypharmacy and drug interactions are common in patients with multiple chronic conditions 1, 3