PHYSIATRIST HISTORY/ANAMNESIS

MINI LECTURE PSPDDEPARTEMEN IKFR UNPAD RSHS

FARIDA ARISANTI SpKFR

PATIENT HISTORYThe 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 COMPLAINTis 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

From a functional view, the elements of communication hinge on four abilities related to speech and language:1. Listening2. Reading3. Speaking4. Writing

• By assessing these factors as well as comprehension and memory, the examiner can determine a patient’s communication abilities.1

Communication con’t

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, goingfrom the prone to supine positions, sitting up, and lyingdown.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?

• 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

TRANSFER

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.

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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 implicationsRepresentative 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?

TOILETINGIneffective 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 following1. 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 independenceRepresentative 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 HISTORY1. 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 statusmarriage 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 HISTORY1. 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

REVIEWOF 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

TERIMAKASIH