What are symptoms and how should they be elicited and documented in a patient assessment?

Understanding and Assessing Symptoms in Clinical Practice

Symptoms are subjective sensations perceived by patients that require systematic elicitation through structured questioning, validated instruments, and integration of both patient and informant perspectives to accurately capture their nature, severity, temporal patterns, and functional impact. 1

Definition and Core Characteristics

Symptoms represent subjective perceptions that differ fundamentally from objective signs. 1 Key defining features include:

• Subjective nature: Symptoms are personal sensations experienced by the patient, not observable findings 1
• Temporal variability: Symptoms may fluctuate over time and require documentation of onset, duration, and progression 2
• Antecedents and influences: Symptoms have underlying mechanisms and can be modified by interventions 1
• Impact on outcomes: Symptoms directly influence functional performance, quality of life, and patient-reported outcomes 1

Systematic Elicitation Strategy

Initial Screening Approach

Begin with validated screening questionnaires completed by patients before or during clinic visits to ensure comprehensive symptom capture. 1 This approach addresses the well-documented gap between clinician perception and actual patient experience—empiric evidence demonstrates that clinicians' reports do not adequately reflect patients' subjective experiences. 1

Recommended screening tools include:

• Gastrointestinal Symptom Rating Scale for GI complaints 1
• Patient Health Questionnaire-15 (PHQ-15) for general somatic symptoms 3
• Visual analogue scales to quantify symptom severity 1
• Bristol Stool Chart for bowel-related symptoms 1

Structured History Taking

The history of present illness must capture specific elements systematically: 2

Temporal characteristics:

• Precise onset timing (acute vs. insidious development) 1, 2
• Duration and frequency of symptoms 2
• Progression or changes over time 2
• Relationship to specific events (though avoid attributing causality prematurely) 1

Symptom characterization:

• Specific descriptive terms rather than vague language 2
• Severity quantification using appropriate scales 2
• Location and radiation patterns where applicable 2
• Quality and character of the sensation 2

Contextual factors:

• Triggers and exacerbating factors 2
• Alleviating factors and what the patient has tried 2
• Associated symptoms that may indicate a cluster or syndrome 1, 2
• Impact on activities of daily living and functional status 2

Critical pitfall: Patients and informants commonly attribute cognitive, behavioral, or physical symptoms to "normal aging," anxiety, mood disorders, or isolated traumatic events when symptoms actually represent underlying disease processes. 1 The clinician must probe beyond these initial attributions through iterative questioning. 1

Multiple Co-occurring Symptoms and Symptom Clusters

When patients present with multiple concurrent symptoms, assess for symptom clusters—stable groups of two or more symptoms that may share underlying mechanisms and should be evaluated together. 1 This is particularly important because:

• Individual symptoms poorly predict underlying pathophysiology 1
• Symptom clusters have independent effects on outcomes 1
• Clusters may have a "driving" symptom that triggers others 1
• Targeted interventions may address multiple symptoms simultaneously 1

Common symptom clusters requiring assessment include pain-fatigue-sleep disturbance, particularly in chronic conditions like cancer, cardiac disease, pulmonary disease, and end-stage renal disease. 1

Incorporating Informant Perspectives

For cognitive, behavioral, or functional symptoms, integrate information from both patient and reliable informants/care partners, as patients may lack insight into their own changes. 1, 2 Validated informant-based instruments include:

• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for cognitive changes 1
• AD8 for brief dementia screening (2-3 minutes) 1
• Quick Dementia Rating System (QDRS) for structured assessment of cognitive, behavioral, and functional changes 1

The clinician must ensure that words used by patients or informants accurately describe observed behavioral changes rather than interpretations. 1 For example, "personality change" requires clarification about whether it stems from apathy, depression, anxiety, or other specific symptoms. 1

Domain-Specific Assessment Requirements

Physical Symptoms in Palliative and Oncology Settings

The most common symptoms requiring systematic assessment include: 1

• Pain (location, character, severity, temporal pattern)
• Dyspnea (severity, triggers, impact on function)
• Anorexia and cachexia
• Nausea and vomiting
• Constipation or diarrhea
• Fatigue, weakness, and asthenia
• Insomnia and daytime sedation
• Delirium

Use validated multisymptom measures appropriate to the clinical context: 1

• EORTC QLQ-C30 for cancer-related symptoms and quality of life 1
• FACT (Functional Assessment of Cancer Therapy) with disease-specific modules 1
• MDASI (MD Anderson Symptom Inventory) for symptom burden 1
• PRO-CTCAE specifically for treatment-related toxicity 1
• PROMIS short forms for selected symptoms and health-related quality of life 1

Gastrointestinal Symptoms

Clinical acumen and individual symptom patterns are unreliable for diagnosing underlying causes in patients with GI complaints, particularly after cancer treatment. 1 More than 30 different GI symptoms may develop, and different physiological disorders cause similar symptoms. 1

Essential trigger questions for GI assessment: 1

1. Do you have frequent loose stools?
2. Do you wake at night needing to defecate?
3. Do you have fecal incontinence?
4. Do you have rectal bleeding or blood in stools?
5. Is your quality of life reduced due to bowel function?
6. Has your mental health been affected by bowel function?

Answering "yes" to any question warrants comprehensive investigation rather than empirical treatment alone. 1

Cardiovascular Symptoms

For breathlessness and fatigue in heart failure: 1

• Recognize that symptoms correlate poorly with severity of cardiac dysfunction 1
• Breathlessness, tiredness, and fatigue are characteristic but require experience and skill to elicit, particularly in elderly patients 1
• Multiple mechanisms contribute: increased pulmonary capillary pressure, skeletal muscle dysfunction, mitral regurgitation, dysrhythmias 1
• Skeletal muscle signals are often interpreted by the brain as breathlessness or fatigue, explaining slow treatment response 1

Neuropsychiatric and Mood Symptoms

Screen systematically for mood and behavioral symptoms, as these are often early features of neurodegenerative disease and may not be recognized by patients or informants as illness-related. 1

For mood assessment: 4

• Begin with PHQ-9 as the primary screening tool (cutoff ≥8 for depression detection) 4
• Follow with GAD-7 for anxiety symptoms 4
• PHQ-9 scores ≥15 require psychiatry/psychology referral 4
• Assess for suicidal ideation (both active and passive) before proceeding 4

Alternative validated instruments include Beck Depression Inventory-II, CES-D, Geriatric Depression Scale for depression, and Beck Anxiety Inventory for anxiety. 4

Critical safety assessment: Evaluate for risk of self-harm, severe depression/agitation, psychosis, or confusion requiring immediate specialist referral. 4

Fatigue and Systemic Symptoms

For comprehensive fatigue evaluation, essential laboratory testing includes: 5

• Thyroid function (TSH, free T4) 5
• Morning cortisol/ACTH (drawn around 8 AM before any steroid administration) 5
• Complete blood count 5
• Comprehensive metabolic panel 5
• Fasting glucose and hemoglobin A1C 5
• Vitamin D 5

Critical timing consideration: Cortisol/ACTH must be drawn in the morning around 8 AM, as physiologic levels vary throughout the day. 5 If both adrenal insufficiency and hypothyroidism coexist, steroids must always be started before thyroid hormone replacement to avoid precipitating adrenal crisis. 5

Documentation Standards

Essential Documentation Elements

Record the following for each symptom: 2

• Onset and duration: Specific timeframe when symptom began 2
• Severity: Quantified using validated scales or descriptors 2
• Character: Specific descriptive terms 2
• Frequency: How often the symptom occurs 2
• Modifying factors: What makes it better or worse 2
• Associated symptoms: Related complaints that may indicate a pattern 2
• Functional impact: Effect on daily activities, work, relationships, quality of life 2
• Patient's perspective: Their understanding and concerns 2
• Previous treatments: What has been tried and effectiveness 2

Avoiding Common Documentation Pitfalls

Do not rely solely on mean group changes when reporting symptom outcomes. 1 Report the proportion of patients experiencing clinically meaningful change from baseline for each measure. 1 Consider including cumulative distribution curves in documentation. 1

Document relevant negatives that help rule out differential diagnoses. 2 This is particularly important when symptoms could indicate serious underlying disease requiring exclusion. 1

Include specific examples of how symptoms manifest in the patient's daily life rather than abstract descriptions. 2 This provides crucial context for treatment decisions and helps other clinicians understand the true impact. 2

Integration with Clinical Decision-Making

Symptom Assessment in Treatment Planning

Symptoms should guide but not solely determine treatment titration for disease-modifying therapies. 1 In heart failure, for example, symptoms relate to prognosis when persistent after therapy but should not guide optimal titration of ACE inhibitors, ARBs, beta-blockers, or aldosterone antagonists, as these drugs impact mortality in ways not closely related to symptoms. 1 Patients should be titrated to optimal tolerated doses regardless of symptom response. 1

Screening for Palliative Care Needs

Screen all patients at every visit for: 1

1. Uncontrolled symptoms
2. Moderate to severe distress related to diagnosis and therapy
3. Serious comorbid physical, psychiatric, and psychosocial conditions
4. Life expectancy of 6 months or less
5. Patient or family concerns about disease course and decision-making
6. Specific requests for palliative care

Patients meeting any screening criterion should undergo comprehensive palliative care assessment. 1

When to Pursue Comprehensive Investigation

If troublesome symptoms do not respond fully to simple empirical intervention, comprehensive investigation is required at an early stage. 1 This is particularly true when:

• Multiple symptoms are present 1
• Symptoms persist despite initial treatment 1
• Functional impact is significant 2
• Red flag features are present (rectal bleeding, unintentional weight loss, progressive neurological symptoms) 1

Special Populations and Contexts

Chronic Disease and Cancer

Patients with chronic conditions experience multiple co-occurring symptoms that remain underdiagnosed and undertreated, negatively impacting functional performance, cognitive status, and quality of life. 1 Symptom burden reduction has potential to improve capacity to live well throughout the disease trajectory. 1

Post-Treatment Surveillance

In patients who underwent treatment with curative intention, recurrence must be considered and ruled out when new or worsening symptoms develop. 1 Additionally, investigate for conditions not associated with the cancer or its treatment. 1

Hospitalized Patients

Symptoms are extremely common at hospital admission (fatigue 80%, dyspnea 60%, cough 51%, dizziness 51%, headache 47%, chest pain 46%, nausea/vomiting 43%) and fail to resolve by discharge 25-50% of the time. 6 Predictors of symptom persistence include shorter length of stay, severity on admission, and total symptom count. 6 Patient satisfaction correlates with symptom severity at discharge and degree of improvement during hospitalization. 6