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

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)

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 cont
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 patients

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 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,

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

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

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,

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

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

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

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?

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

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

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.

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

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?

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

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, selfesteem, 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?

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,

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

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

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

TERIMA

KASIH