PHYSIATRIST

HISTORY/ANAMNESIS
MINI LECTURE PSPD
DEPARTEMEN IKFR UNPAD RSHS

FARIDA ARISANTI SpKFR

 PATIENT HISTORY
The major components of the patient history are :
• Chief report of symptoms/chief complaint
• the history of the present illness
• the functional history
• the past medical history
• the patient profile (Personal, social &
vocational history)
• and the family history
• a review of systems1
 CHIEF COMPLAINT
is the symptom or concern that caused the
patient to seek medical treatment
 The most common chief complaints seen in an
outpatient physiatric practice : pain, weakness,
or gait disturbance of various musculoskeletal
or neurologic origins.
 purely subjective
 can also allude to a degree of disability or
handicap (difficulty of walking due to knee pain,
vocational disturbance due to low back pain).2
 HISTORY OF PRESENT ILLNESS (HPI)

 The history of the present illness (HPI) details

the chief complaint(s) as well as any related or
unrelated functional deficits.2
 should include some or all of eight
components related to the chief complaint:
location, time of onset, quality, context,
severity, duration, modifying factors, and
associated signs and symptoms.1,2
 Examples....
a 70-year-old man referred by his neurologist because the
patient cannot walk properly (chief complaint)

• Over the past few months (duration), he has noted slowly

progressive weakness of his left leg (location)
• Subsequent workup by his neurologist suggested amyotrophic
lateral sclerosis (context)
• The patient was active in his life and working up until a few
months previously, ambulating without an assistive device
(context)
• Now he uses a straight cane for fear of falling (modifying factor)
• the patient also has some trouble swallowing foods (associated
signs and symptoms).2
 FUNCTIONAL STATUS

• Detailing the patient’s current and prior

functional status is an essential aspect of the
physiatric HPI.1,2
 FUNCTIONAL STATUS cont..
 is sometimes helpful to assess functional
status using a standardized scale
 the Functional Independence Measure (FIM) is
the most commonly used in the inpatient
rehabilitation setting
 each of 18 different activities is scored on a
scale of 1 to 7, with a score of 7 indicating
complete independence
FIM con’t.....
 COMMUNICATION
• Communication skills are used to convey
information including thoughts, needs, and
emotions.
• Patients who cannot communicate through
speech might or might not be able to
communicate through other means include
writing and physicality (such as sign language,
gestures, and body language)
• depending on the type of communication
dysfunction and other physical and cognitive
limitations.2
 Communication con’t
From a functional view, the elements of
communication hinge on four abilities related to
speech and language:
1. Listening
2. Reading
3. Speaking
4. Writing
• By assessing these factors as well as comprehension
and memory, the examiner can determine a
patient’s communication abilities.1
Representative questions include the following:
1. Do you have difficulty hearing?
2. Do you use a hearing aid?
3. Do you have difficulty reading?
4. Do you need glasses to read?
5. Do others find it hard to understand what you say?
6. Do you have problems putting your thoughts into
words?
7. Do you have difficulty finding words?
8. Can you write? Can you type?
9. Do you use any communication aids?1
 MOBILITY
• Mobility is the ability to move about in one’s
environment and is taken for granted by most
healthy people
• it plays such a vital role in society, any
impairment related to mobility can have major
consequences for a patient’s quality of life
• needed to determine independence and safety,
including the use of, or need for, mobility
assistive devices (crutches, canes, walkers,
orthoses, manual and electric wheelchairs)
BED MOBILITY
 The most basic stage of functional mobility is independence in bed
activities.1
 Bed mobility includes turning from side to side, going
from the prone to supine positions, sitting up, and lying
down.1,2
 A lack of bed mobility places the patient at greater risk for skin
ulcers, deep vein thrombosis, and pneumonia.
 In severe cases, bed mobility can be so poor as to require a caregiver.2
 For the person who cannot stand upright to dress, bridging (lifting the
hips off the bed in the supine position) will allow the donning of
underwear and slacks1
 BED MOBILITY...con’t...
Representative questions include the following:
1. When lying down, can you turn onto your front,
back, and sides without assistance?
2. Can you lift your hips off the bed when lying on
your back?
3. Do you need help to sit or lie down?
4. Do you have difficulty maintaining a seated
position?
5. Can you operate the bed controls on an electric
hospital bed?
 TRANSFER
• The second stage of functional mobility is
independence in transfers.1
• Transfer mobility includes getting in and out of
bed, standing from the sitting position (whether
from a chair or toilet), and moving between a
wheelchair and another seat (car seat or shower
seat).2
• Being able to move between a wheelchair and the
bed, toilet, bath bench, shower chair, standard
seating, or car seat often serves as a precursor to
independence in other areas. 1
 Also included in this category is the ability to rise
from a seated position to a standing position
Representative questions include the following:
1. Can you move to and from the wheelchair to the
bed, toilet, bath bench, shower chair, standard
seating, or car seat without assistance?
2. Can you get out of bed without difficulty?
3. Do you require assistance to rise to a standing
position from either a low or a high seat?
4. Can you get on and off the toilet without help?
 WHEELCHAIR MOBILITY
 Although wheelchair independence is more
likely than walking to be inhibited by
architectural barriers, it provides excellent
mobility for the person who is not able to walk
• Wheelchair mobility can be assessed by asking
if patients can propel the wheelchair
independently, how far or how long they can
go without resting, and whether they need
assistance with managing the wheelchair parts
 Representative questions in wheelchair
mobility :
1. Do you propel your wheelchair yourself?
2. Do you need help to lock the wheelchair brakes before
transfers?
3. Do you require assistance to cross high-pile carpets,
rough ground, or inclines in your wheelchair
4.How far or how many minutes can you wheel before
you must rest?
5. Can you move independently about your living room,
bedroom, and kitchen?
6. Do you go out to stores, to restaurants, and to friends’
homes?
 AMBULATION
 The final level of mobility is ambulation
 Ambulation may be any useful means of
movement from one place to another1
 Ambulation can be assessed by how far or for
how long patients can walk, whether they
require assistive devices, and their need for rest
breaks. 2
 also important to know whether any symptoms
are associated with ambulation :chest pain,
shortness of breath, pain, or dizziness
Representative questions include the following:
1. Do you walk unaided?
2. Do you use a cane, crutches, or a walker to walk?
3. How far or how many minutes can you walk before
you must rest?
4. What stops you from going farther?
5. Do you feel unsteady or do you fall?
6. Can you go upstairs and downstairs unassisted?
7. Do you go out to stores, to restaurants, and to
friends’ homes?
8. Can you use public transportation?2
 Operation of a Motor Vehicle
• Driving is a crucial activity for many people, not
only as a means of transportation but also as
an indicator and facilitator of independence.1,2
• For example, elders who stop driving have an
increase in depressive symptoms.
• It is important to identify factors that might
prevent driving, such as decreased cognitive
function and safety awareness, and decreased
vision or reaction timelower limb weakness,
contracture, or dyscoordination
• Representative questions include the
following :
1. Do you have a valid driver’s license?
2. Do you own a car?
3. Do you drive your car to stores, to restaurants,
and to friends’ homes?
4. Do you drive in heavy traffic or over long
distances?
5. Do you drive in low light or after sunset?
 ACTIVITY OF DAILY LIVING (ADL)
• ADL encompass activities required for
personal care including feeding, dressing,
grooming, bathing, and toileting.
• I-ADL encompass more complex tasks required
for independent living in the immediate
environment such as care of others in the
household, telephone use, meal preparation,
house cleaning, laundry, and in some cases
use of public transportation.
Dikutip dari
Braddom.1
 EATING
• The abilities to present solid food and liquids to
the mouth, to chew, and to swallow are basic
skills
Representative questions include the following:
1. Can you eat without help?
2. Do you have difficulty opening containers or
pouring liquids?
3. Can you cut meat?
4. Do you have difficulty handling a fork, knife, or
spoon?1
5. Do you have problems bringing food or
beverages to your mouth?
6. Do you have problems chewing?
7. Do you have difficulty swallowing solids or
liquids?
8. Do you ever choke?
9. Do you regurgitate food or liquids through
your nose?
• The type, quantity, and schedule of feedings
should be recorded.
 GROOMING
• impaired functioning that leads to deficits in
grooming can have deleterious effects on hygiene
as well as on body image and self-esteem.1
Representative questions include the following:
1. Can you brush your teeth without help?
2. Do you have problems fixing or combing your
hair?
3. Can you apply your makeup independently?
4. Do you have problems shaving?
5. Can you apply deodorant without assistance?1
 BATHING
• The ability to maintain cleanliness also has far-
reaching physical and psychosocial implications
Representative questions include the following:
1. Can you take a tub bath or shower without
assistance?
2. Do you feel safe in the tub or shower?
3. Do you use a bath bench or shower chair?
4. Can you accomplish a sponge bath without help?
5. Are there parts of your body that you cannot
reach?
 TOILETING
 Ineffective bowel or bladder control has an
adverse impact on self-esteem, body image, and
sexuality, and it can lead to participation
restriction
Representative questions include the following
1. Can you use the toilet without assistance?
2. Do you need help with clothing before or after
using the toilet?
3. Do you need help with cleaning after a bowel
movement?
 Toileting con’t..
• For patients with indwelling urinary catheters,
management of the catheter and leg bag
should be examined.
• If bladder emptying is accomplished by
intermittent catheterization should be
determined who performs it and should have
a clear understanding of his or her technique
 DRESSING
• We dress for protection, warmth, self-esteem, and
pleasure.
• Dependency in dressing a severe limitation to
personal independence
Representative questions include the following:
1. Do you dress daily?
2. Do you require assistance putting on or taking off
your underwear, shirt, slacks, skirt, dress, coat,
stockings, panty hose, shoes, tie, or coat?
3. Do you need help with buttons, zippers, hooks,
snaps, or shoelaces?
 COGNITION
• Cognition is the mental process of knowing
• impairments in cognition can also become
apparent during the course of the history
taking.
• Cognitive deficits and limited awareness of
these deficits are likely to interfere with the
patient’s rehabilitation program unless
specifically addressed.
 PAST MEDICAL HISTORY
• record of any major illness, trauma, or health
maintenance since the patient’s birth.1
•  allows the physiatrist to understand how
preexisting illnesses affect current status, and
how to tailor the rehabilitation program for
precautions and limitations.2
 NEUROLOGIC, MUSCULOSKELETAL &

CARDIOPULMONARY DISORDERS,
MEDICATIONS
 PERSONAL HISTORY
1. Lifestyle
 Avocational : recreational or leisure interest,
sports (frequency, duration, intensity), intelectual
pursuit, organizations, group functions)
 Diet : dietary habits, caffeine use, meal, snacks
 Cigarette smoking : quantity
 Sexual history :sexual preference, sexual
experience, sexual promisquity
 Alcohol use : alcohol abuse1,3
2. Psychological and Psychiatric History
• seek a history of previous psychiatric
hospitalization, psychotropic pharmacologic
intervention, or psychotherapy.
• The patient should be screened for past or
current anxiety, depression and other mood
changes, sleep disturbances, delusions,
hallucinations, obsessive and phobic ideas,
and past major and minor psychiatric
illnesses.1
3. Religious Belief.
• Spirituality is an important part of the lives of
many patients have positive effects on
rehabilitation, life satisfaction, and quality of
life.2
• Health care providers should be sensitive to
the patient’s spiritual needs, and appropriate
referral or counseling should be provided.2,3
 SOCIAL HISTORY
1. Home situation and architectural barriers
• determine whether the patient owns or rents the
home, the location of the home (e.g., urban,
suburban, or rural)
• the distance between the home and rehabilitation
services, the number of steps into the home
• the presence of (or room for) entry ramps, and
the accessibility of the kitchen, bath, bedroom,
and living room.1,3
• Home visit might be required to gain the best
assessment
2. Marriage history and status
marriage conditions

3. Family, significant others, support system

• Patients who have lost function might require
supervision, emotional support, or actual
physical assistance.
• Family, friends, and neighbors who can provide
such assistance should be identified.
• The clinician should discuss the level of
assistance they are willing and able to provide.1,3
 VOCATIONAL HISTORY
1. Education and Training
• educational level achieved by the patient may
suggest intellectual skills
• The acquisition of special skills, licenses, and
certifications should be noted.
• Future vocational goals are always important
to address but are of particular concern with
adolescent patients.1
2. Work History
• patient’s work experience can help determine
the need for further education and training
• also provides an idea of the patient’s
motivation, reliability & self-discipline
• actual job descriptions must be obtained, &
the patient should be asked about
architectural barriers within work place.1
3. Financial situation, Insurance & Litigation
 source of income
 Investments
 insurance resources
 Debt
 litigation status3
 FAMILY HISTORY
• can be used to identify hereditary disease in
the family & to assess the health of people in
the patient’s home support system.
• Knowledge of the health and fitness of the
spouse and other family members can aid
dismissal planning.1,2,3

diabetes, cancer, rheumatology, hipertension,
stroke, kidney disease, psychiatric disorders
etc
REVIEW
OF SYSTEMS
 REFFERENCES
1. Aksoy I.A., Freeman J.A ., Paynter K.S., Ganter B.K. Clinical
evaluation. In Delisa, Joel A. Physical medicine and
rehabilitation. 5th edition. Lippincot;William & Wilkins.
2010. page 1-20
2. O’Dell, M.W., Lin, C.D., and Panagos, A. The Physiatric
History and Physical Examination. In Braddom: Physical
Medicine and Rehabilitation. 4th ed. Elsevier Saunders.
2011. page 1-22
3. C. Tan. Clinical evaluation and Documentation. In Practical
Manua; of Physical medicine and rehabilitation. 2nd ed.
Mosby elsevier. 2006. Page 1-5
TERIMA
KASIH