PHYSIATRIST

HISTORY/ANAMNES
IS
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 patients 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 cont.....

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
From a functional view, the elements of
cont
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 patients communication
abilities.1

Representative questions include

the following:
1.
2.
3.
4.
5.

Do you have difficulty hearing?

Do you use a hearing aid?
Do you have difficulty reading?
Do you need glasses to read?
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
ones 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 patients 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...cont...
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 drivers 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 selfesteem.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 cont..
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 patients
rehabilitation program unless
specifically addressed.

PAST MEDICAL HISTORY

record of any major illness, trauma, or
health maintenance since the patients
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 patients 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
patients work experience can help
determine the need for further
education and training
also provides an idea of the patients
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 patients
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. ODell, 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 15

TERIM
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KASIH