Physiatric Evaluation 9.

Review of System

1. DATA- NASACORN System Question

2. Left/Right Handedness Systemic Any general symptoms, such
as fever, weight loss,
3. Chief Complaint fatigue, nausea, and poor
appetite?
4. History of Present Illness Any skin problems? Sores?
Skin
a. Why the patient is seeking help Rashes? Growths? Itching?
Changes in hair or nails?
b. Pain- Location, Time of onset, Dryness?
Quality, Severity, Duration, Eyes Any changes in vision? Pain?
Redness? Double vision?
Modifying Factors, Associated Watery eyes? Dizziness?
Signs and Symptoms Ears How are the ears and
hearing? Running ears?
5. Functional Status Poor hearing? Ringing ears?
a. Mobility: Bed mobility, Transfers, Discharge?
Nose How are your nose and
Wheel Chair, mobility, ambulation, sinuses? Stuffy nose?
driving and devices required. Discharge? Bleeding?
Unusual odors?
b. Activities of Daily Living: Bathing, Any problems with your
Mouth
Toilet, Dressing, Eating, and mouth? Sores? Bad taste?
Sore tongue? Gum trouble?
grooming
Throat and Neck Any problems with your
c. Instrumental Activities of Daily throat and neck? Sore
Living: Meal Preparation, Laundry, throat? Hoarseness?
Swelling? Swallowing?
Telephone use, home Any problems with your
Breast
maintenance, pet care, etc. breasts? Lumps? Nipple
discharge? Bleeding?
d. Cognition- memory, orientation, Swelling? Tenderness?
Executive functioning Pulmonary Any problems with your
e. Communication lungs or breathing? Cough?
Sputum? Bloody sputum?
Pain in the chest on taking a
6. Past Medical and Surgical History deep breath? Shortness of
breath?
a. History of prev hospitalization Cardiovascular Do you have any problems
with your heart? Chest
b. Medical Condition such as DM, pain? Shortness of breath?
HPN, Cardiac Prob, Prev Stroke Palpitations? Cough?
Swelling of your ankles?
Attack Trouble lying flat in bed at
night? Fatigue?
Gastrointestinal Male: Any problems with
7. Social History- Current occupation, your kidneys or urination?
Married/Single, History of vices and Painful urination?
Frequency? Urgency?
substance abuse Nocturia? Bloody or cloudy
urine? Trouble starting or
a. Home environment and living stopping? Female: Number
circumstances, family and friends support of pregnancies? Abortions?
system, substance abuse, sexual history, Miscarriages? Any
vocational activities, finances, recreational menstrual problems? Last
activities, psychosocial history (mood menstrual period? Vaginal
disorders), spirituality, and litigation bleeding? Vaginal
discharge? Cessation of
periods? Hot flashes?
8. Family History- presence of Vaginal itching? Sexual
dysfunction?
heredofamilial disease Endocrine Any problems with your
endocrine glands? Feeling
 hot or cold? Fatigue? What GCS
Changes in skin or hair?
Frequent urination? Fatigue
Musculoskeletal Do you have any problems
with your bones or joints?
Joint or muscle pain?
Stiffness? Limitation of
motion
Nervous System Numbness? Weakness? Pins
and needles sensation?

Physical Examination

Neurologic Exam

Mental Status Exam

1. Level of Consciousness
Awake, Lethargic, Obtundation,
Stupor, Coma
Lethargy- general slowing of motor
processes such as speech and
movement; easily falls asleep and
aroused when stimulated
Obtundation- dulled or blunted
sensitivity in which the patient is
difficult to arouse and once
aroused, is still confused.
Stupor- state of semiconscious,
needs intense arousal like sharp
pressure (sternal rub) and the
patient has few or even no
voluntary motor responses
Coma, the eyes are closed with
absence of sleep-wake cycles and
no evidence of a contingent rela-
tionship between the patients
behavior and the environment.
Vegetative state is characterized by
the presence of sleep-wake cycles
but still no contingent relationship
Minimally conscious state indicates
a patient who remains severely
disabled but demonstrates sleep-
wake cycles and even inconsistent,
nonreflexive, contingent behaviors
in response to a specific
environmental stimulation