How do patients describe their functional status in a review of systems?

How Patients Describe Their Functional Status in Review of Systems

Patients describe their functional status by reporting their ability to perform specific physical activities, symptom burden during exertion, and limitations in daily living tasks, typically using concrete examples like walking distance, stair climbing capacity, and self-care abilities. 1, 2

Symptom-Based Descriptions

Patients commonly describe functional limitations through cardiovascular and respiratory symptoms:

• Dyspnea patterns: Patients report uncomfortable awareness of breathing at rest, during specific activities (running, walking on inclines or flat surfaces, dressing, standing), or while lying flat (orthopnea requiring 3+ pillows). 1
• Paroxysmal nocturnal dyspnea: Patients describe suddenly awakening from sleep with breathing discomfort lasting >5 minutes, relieved by sitting upright. 1
• Fatigue: Patients report unusual tiredness and inability to perform usual activities, with specific onset dates and duration. 1
• Volume-related symptoms: Patients describe weight changes (in pounds/kilograms over specific timeframes) and swelling in extremities or abdomen. 1

Activity-Based Capacity Descriptions

Patients quantify functional status through specific physical activities:

• Walking capacity: Patients report whether they can walk 4 blocks without stopping, which correlates with <4 METs capacity and predicts cardiovascular risk. 2
• Stair climbing: Patients describe ability to climb 2 flights of stairs without stopping, a key functional threshold. 2
• Activity-specific limitations: Patients detail the degree of exertion required to elicit symptoms—whether during sports, household tasks (shopping, housework), or basic self-care (dressing). 1

Daily Living Function Descriptions

Basic Activities of Daily Living (BADLs)

Patients describe limitations in fundamental self-care tasks necessary for home independence:

• Self-care abilities: Bathing, dressing, toileting, transferring, and feeding. 3
• Mobility: Walking and moving within the home environment. 1

Instrumental Activities of Daily Living (IADLs)

Patients report capacity for complex community-based tasks:

• Domestic tasks: Cooking, cleaning, laundry, and household management. 1
• Community activities: Shopping, managing finances, using transportation, and medication management. 3
• Frequency and difficulty: Patients describe how often they perform activities, duration of performance, degree of difficulty, and satisfaction with performance. 1

Structured Assessment Approaches

Disease-Specific Descriptions

Heart failure patients describe:

• Specific activity levels that trigger dyspnea (e.g., "stopping to rest while dressing" or "walking 50 feet on flat ground"). 1
• Changes in symptoms since last visit (better, worse, unchanged). 1
• Urinary continence status (continent, occasionally incontinent, totally incontinent). 1

Pulmonary disease patients describe:

• Problematic daily activities from predefined lists (Manchester Respiratory Activities of Daily Living Scale, London Chest Activity of Daily Living scale). 1
• Walking may not be an important goal for up to one-third of individuals, highlighting variability in patient priorities. 1

Stroke patients answer three essential questions:

• "What could you do before the stroke that you cannot do now?" 2
• "What do you want to be able to do?" 2
• "Have you reached your full potential for recovery?" 2

MET-Level Activity Descriptions

Patients describe activities that correlate with metabolic equivalent (MET) levels:

Activities indicating poor functional capacity (<4 METs):

• Slow ballroom dancing, playing musical instruments while seated, walking 2-3 mph on flat ground, golfing with a cart. 2

Activities indicating adequate functional capacity (≥4 METs):

• Moderate cycling, climbing hills, singles tennis, jogging, ice skating, rollerblading. 2

Common Clinical Pitfalls

• Physician underestimation: Physicians document functional limitations in only 5% of patients for physical function and 4% for emotional function, while patients self-report 12% and 8% respectively—a statistically and clinically significant gap. 4
• Medical record inadequacy: 61-98% of medical records lack documentation of individual ADLs and IADLs (except walking at 24%), with poor sensitivity (44-95%) for detecting impairment. 5
• Assumption errors: Assuming nondocumentation equals independence is unwarranted and leads to missed functional deficits. 5
• Self-report versus objective measures: Exercise capacity measured by field tests (6-minute walk) does not correlate strongly with self-reported physical activity levels or problematic daily activities, requiring both types of assessment. 1