History-taking skills are part of the art of medicine and are required to fulh- assess a patient's presentation. One of the unique aspects of ph\'siatn' is the recognition of functional deficits caused by illnes or injury. Identification of these deficits allows for the design of a treatment program to restore performance. In a person with stroke, for example, the most important questions for the physiatrist are not just the
etiology or location of the lesion but also what functional deficits are present as a result of the stroke" The answer could include deficits in swallowing, communication, mobilitycognition, activities of daily living (ADL) , or a combination of these.
The time spent in taking a history also allows the patient to become familiar with the physician, establishing sympathy and trust. This initial rapport is critical for a constructive and productivedoctor-patitent-family relationship, and can also helps the physician learn about such sensitive areas as the sexual
history and substance abuse. It can also have an impact on outcome, as a trusting patient tends to be a more compliant patient. Assessing the tone of the patient and/or family (such as anger, frustration, resolve, and determination), understanding of the illness, insight into disability, and coping skills are also
deaned during history taking. In most cases, the patient leads the physician to a diagnosis and conclusion. In other cases, such as when the patient is rambling and disorganized, frequent
redirection and refocus are required.
Patients are generally the primary source of information.However, patients with cognitive or mood deficits (denial or decreased insight) or with communication problems, as well as small children, might not be able to fully express themselves.
In these cases, the history taker might rely on other sources, such as family members; friends; other physicians, nurses, and medical professionals; or previous medical records. Caution
must be exercised in using previous medical records, as inaccuracies are sometimes reported from provider to provider, sometimes referred to as 'chart lore'.
The chief complaint is the symptom(s) that caused the patient to seek medical treatment. The most common chief complaints seen in an outpatient physiatric practice are pain or weakness of various musculoskeletal or neurologic origins. On a physiatric consultation on an inpatient rehabilitation service, the predominant chief complaints are related to mobility, ADL, communication, or cognitive deficits. Unlike the relatively objective physical examination, the chief complaint is a subjective measure and, when possible, the physician should use the patient's own words. A patient can present with several related or unrelated complaints, in which case it is helpful to have the patient rank problems from 'most bothersome' to 'least
bothersome'. The specific circumstance of a patient offering a chief complaint can also allude to a degree of disability or handicap. For example, knowing that an obese mail carrier presents with the chief complaint of difficulty in walking because of knee pain could suggest not only the impairment, but also that he might
no longer be able to perform his duties as a mail carrier.
History of the present illness
The HPI details the chief complaint(s) for which the patient is seeking medical attention, as well as any related or unrelated functional deficits. It should also explore other information relating to the chief complaint, such as recent and past medical or surgical procedures, complications of treatment, and potential restrictions or precautions. The HPI 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.
In this case example, the patient is a 70-year-old man referred by his neurologist for physical therapy 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 work-up 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).
Besides difficultywith walking, the patient also has some trouble swallowing foods (associated signs and symptoms).
Detailing the patient's current and prior functional status is an essential aspect of the physiatric HPJ. This generalh- entails better understanding the issues surrounding mobility, ADL, instrumental acthities of daily living (I-ADL), communication, and cognition, among others. The data should be as accurate and detailed as possible in order to guide the physical examination and develop a treatment plan with reasonable short-and
long-term goals. Assessing the potential for functional gain or deterioration requires an understanding of the natural history, cause, and time of onset of the functional problems. For example, most motor recovery following stroke occurs within 3-6 months of the event. For a recent stroke patient with considerable motor impairments, there is a greater expectation for functional gain than in a patient with minor deficits related to a stroke 2 years ago. On the other hand, functional gains in speech deficits canstill be seen beyond 1 year post stroke.
It is sometimes helpful to assess functional status using a standardized scale. No single scale is appropriate for all patients, but the Functional Independence Measure (FIM) is the most commonly used in the inpatient rehabilitation setting Measuring only disability or performance, each of 18 different activities is scored on a scale of 1-7, with a score of 7 indicating complete independence. Intermediate scores indicate varying levels of
assistance from very little (from an assistive device, to supervision, to hands-on assistance). A score of 1 indicates complete dependence on caregiver assistance. FIM scores also serve as a kind of rehabilitation shorthand among team members to quickly and accurately describe functional deficits.
Mobility is the ability to move about in one's environment and is taken for granted by most healthy people. Because it plays such a vital role in society, any impairment related to mobility can have major consequences for a patient's quality of life. A clear understanding of the patient's functional mobility is needed to determine independence and safety, including the use of, or need for, mobility assistive devices. There is a range of mobility assistive devices that patients can use, such as crutches, canes, walkers, orthoses, and manual and electric wheelchairs, among others.
Bed mobility includes turning from side to side, going from the prone to supine positions, sitting up, and lying down. A lack of bed mobility puts 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. In other cases,
bed rails might be appropriate to facjlitate movement. 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). Once again, the history taker should assess the level of independence, safety, and any changes in functional ability. 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. It is also important to assess the extent to which they can move about at home, in the community, and up and down ramps. Whether the home is potentially wheelchair-accessible is particularly important in cases of new
onset having severe disability.
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. It is also important to know if any
symptoms are associated with ambulation, such as chest pain, shortness of breath, pain, or dizziness, Patients should be asked about any history of falling or instability while walking, and their ability to navigate uneven surfaces. Stair mobility, along with the number of stairs the patient must routinely climb and descend at home or in the community, and the presence or absence of handrails should also be determined.
Driving is a critically important activity for many people, not only as a means of transportation but also as an indication and facilitator of independence. 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 time. Other factors affecting driving can include lower limb weakness, contracture, tone, or dyscoordination.
Some of these conditions might require use of adaptive hand controls for driving. Cognitive impairment sufficient to affect the ability to drive can be due to medications or organic disease (dementia, brain injury, stroke, or severe mood disturbance). Ultimately, the risks of driving are weighed against the consequences of not being able to drive. If the patient is no longer able to drive, alternatives to driving should be explored,
such as the use of public or assisted transportation. Laws differ widely from state to state on the return to driving after a neurologic impairment develops.
Activities of daily living and instrumental activities of daily living
Activities of daily living encompass activities required for personal care, including feeding, dressing, grooming, bathing, and toileting. I-ADL encompass more complex tasks required for independent b-ing 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.
·In the Occupational Therapy Practice Framework, there are 11 activities for both ADL and I-ADL
• Bathing and showering
• Bowel and bladder management
• Functional mobility
• Personal device care
• Personal hygiene and grooming
• Sexual activity
• Sleep and rest
• Toilet hygiene
• Care of others (including selecting and supervising caregivers)
• Care of pets
• Child rearing
• Communication device use
• Community mobility
• Financial management
• Health management and maintenance
• Home establishment and management
• Meal preparation and clean-up
• Safety procedures and emergency responses
The clinician should identify and document ADL the patient can and cannot perform, and determine the causes of limitation. For example, a woman with a stroke might state that she cannot put on her pants. This could be due to a combination of factors such as a visual field cut, balance problems, weakness, pain, contracture, tone, or deficits in motor planning. Some of these factors can be confirmed later in the physical examination. A more detailed follow-up to a positi\'e response to the question is frequently needed. For example, a patient might say 'yes' to the question 'Can you eat by yourself?' On further questioning, it might be learned that she cannot prepare the food by herself or cut the food independently. The most accurate assessment of ADL and mobility deficits often comes from the hands-on assessment by other members of the rehabilitation team.
Cognition is the mental process of knowing. Although objective assessment of cognition comes under physical examination (memory, orientation, and the ability to assimilate and manipulate information). impairments in cognition can also become apparent during the course of the history taking.
Because persons with cognitive deficits often cannot recognize their Own impairments (deficits in insight), it is important to gather information from family members and others familiar with the patient. Cognitive deficits and limited awareness of these deficits are likely to interfere with the patient's rehabilitation program unless specifically addressed. These deficits can pose a safety risk as well. For example, a man with a previous
stroke who falls, sustaining a hip fracture, might not be able to follow hip precautions, resulting in possible refracture or hip dislocation. Executive functioning is another aspect of cognition, which includes the mental functions required for planning, problem solving. and self-awareness. Executive functioning correlates
with functional outcome because it is required in many real world situations.
Communication skills are used to convey information, including thoughts, needs, and emotions. Verbal expression deficits can be very subtle and might not be noticed in a first encounter. If there is a reason to think that speech or communication has been affected by a recent event, it is advisable to ask family
members if they have noticed recent changes. Patients who cannot communicate through speech might or might not be able to communicate through other means, known as augmentative communication, depending on the type of communication dysfunction and other physical and cognitive limitations. This can include writing and physicality (such as sign language, gestures, and body language). They can also utilize a variety of
augmentative communication aids ranging from simple picture, letter, and word boards to electronic devices.
Past medical and surgical history
The physiatrist needs to understand the patient's past medical and surgical history. This knowledge allows the physiatrist to review and address functional deficits caused by preexisting illnesses, and to tailor the rehabilitation program for precautions and limitations. The patient's past medical history can also
have a major impact on rehabilitation outcome.
Mobility, ADL, l-ADL, work, and leisure can be severely compromised by cardiopulmonary deficits. The patient should be asked about any history of congestive heart failure, recent and distant myocardial infarction, arrhythmias, and coronary artery disease. Past surgical procedures such as bypass surgery, heart transplantation, stent placement, and recent diagnostic testing (stress test or echocardiogram) should be ascertained, This information is important to ensure that exercise prescriptions do not exceed cardiovascular activity limitations, Patients should also be asked about their activity tolerance, surgery such as lung volume reduction or lung transplant, and whether they require horne oxygen, Dyspnea from chronic obstructive pulmonary disease can be a significant contributor to functional limitations, It is also important to identify modifiable risk factors for cardiac disease, such as smoking, hypertension, and obesity.
There can be a wide range of musculoskeletal disorders from acute traumatic injuries to gradual functional decline with chronic osteoarthritis, The patient should be asked about any history of trauma, arthritis, amputation, joint contractures, musculoskeletal pain, congenital or acquired muscular problems, weakness, or instability. It is important to understand the functional impact of such impairments or disabilities. Patients
with chronic physical disability often develop overuse musculoskeletal syndromes, such as the development of shoulder pain secondary to chronically propelling a wheelchair.
Preexisting congenital or acquired neurologic disorders can have a profound impact on the patient's function and recovery from both neurologic and non-neurologic illness. It is helpful to know whether a neurologic disorder is congenital versus acquired, progressive versus non-progressive, central versus peripheral,
demyelinating versus axonal, or sensory versus motor. This information can be helpful in understanding the pathophysiology, location, severity, prognosis, and implications for management. The interviewer must assess the premorbid need for assistive devices, orthoses, and the degree of speech, swallowing, and cognitive impairments.
The history should assess the type of rheumatologic disorder, time of onset, number of joints affected, pain level, current disease activity, and past orthopedic procedures. Discussions with the patient's rheumatologist might address whether medication changes could improve activity tolerance in a rehabilitation program.
All medications should be documented, including prescription and over the counter drugs as well as nutraceuticals, supplements, herbs, and vitamins. Patients typically do not mention medications that they do not think are relevant to their current problem, unless asked about them in detail. Drug and food allergies should be noted. It is especially important to gather the complete list of medications being used in patients who are seeing multiple physicians. Particular attention should be paid to non-steroidal antiinflammatory agents, because these are commonly prescribed by physiatrists for musculoskeletal disorders and care must be taken not to double-dose the patient. The indications, precautions, and side effects of all drugs prescribed
should be explained to the patient.
Home environment and living situation
Understanding the patient's home environment and living situation includes asking if the patient lives in a house or an apartment, if there is elevator access, whether it is wheelchairaccessible, if there are stairs, whether the bathroom is accessible from the bedroom, and whether the bathroom has grab bars or handrails (and on which side). A home visit might be required to gain the best assessment. If there is no caregiver at home,
the patient could require a home health aide. These factors help determine many aspects of the discharge plan.
Family and friends support
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 b·el of assistance they are willing and able to provide. The assistance provided by caregivers
can be limited if they are elderly, have some type of impairment, work, or are not willing to assist with bowel
or bladder hygiene.
Patients should be asked about their history of smoking, alcohol use or abuse, and drug abuse. Because patients often deny substance abuse, this topic should be discussed in a non-judgmental manner. Patients frequently feel embarrassment or guilt in admitting substance abuse, and also fear the legal consequences
of such admission. Substance abuse can be a direct and an indirect cause of disability, and is often a contributing factor in traumatic brain injury,15 It can also have an impact on community reintegration, because patients with pain and/or depression are at risk of further abuse. Patients who are at risk should
be referred to social work to explore options for further assistance, either during the acute rehabilitation or later in the community.
Patients and healthcare practitioners alike are often uncomfortable discussing the topic of sexuality, so developing a good rapport during history taking can help. Discu~sion of this topic is made easier if the healthcare practitioner has a good knowledge of how sexual function can be changed by illness or injury.
Sexuality is particularly important to patients in their reproductive years (such as most spinal cord and braininjured persons), but the physician should enquire about sexuality in adolescents and adults of all ages. Sexual orientation and safer sex practices should be addressed when appropriate.
Finances and income maintenance
Patients can have financial concerns that are due to or exacerbated by their illness or injury. These concerns can also be addressed by the rehabilitation team social worker. Whether a patient has the financial resources or insurance to pay for adaptive devices such as a ramp or mobility equipment can significantly
impact discharge planning, If patients cannot safely be discharged home, skilled nursing facility placement might need to be explored, at least on a temporary basis.
The ability to engage in hobbies and recreational activities is important to most people, and any loss or limitation of the ability to perform these activities can be stressful. The recreational activity affected can im'olve physical exercise, such as a sporting activity, or can be more sedentary, for example playing
cards, The team recreational therapist can be helpful in helping to restore the patient's favorite recreations and offer new ones.
The history taker must recognize the psychosocial impact of impairment. Beyond the loss of function, the patient can also feel a loss of overall health, body image, mobility, or independence.
The loss of function, and possibly of income as welL can place great stress on the family unit and caregivers. The treatment plan should recognize the patient's psychosocial context and provide assistance in developing coping strategies ,especially for depression and anxiety. This can help accelerate the patient's process of adjusting to a new disability.
Spirituality and belief
Spirituality is an important part of the lives of many patients, and some preliminary studies indicate that it can have positive effects on rehabilitation, life satisfaction, and quality of life. Healthcare providers should be sensitive to the patient's spiritual needs, and appropriate referral or counseling should be provided.
Patients should be asked, in a non-judgmental way, if they are involved in litigation related to their illness, injuries, or functional impairment. The answer should not change your treatment plan, but litigation can be a source of anxiety, depression, or guilt. In some cases, the patient's legal representation can play an important role in obtaining needed services and equipment.
Patients should be asked about the health, or cause and age of death, of parents and siblings. It is always important to know whether any family members have a similar condition. They should also be asked about any family history of heart disease, diabetes, cancer, stroke, arthritis, hypertension, or neurologic illness. This will help to identify genetic disorders within the family. A knowledge of the general health of family members
can also provide insight into their ability to provide functional assistance to the patient.
Review of systems
A detailed review of organ systems should be done in order to discover any problems or diseases not previously identified during the course of the history taking.
Table lists some questions that can be asked about each system. Note that this
list is not comprehensive, and more detailed questioning might be necessary.
Systemic Any general symptoms such as fever, weight loss, fatigue, nausea, and poor appetite?
Skin Any skin problems? Sores? Rashes? Growths? Itching? Changes in the hair or nails? Dryness?
Eyes Any changes in vision? Pain? Redness? Discharge? Double vision? Watery eyes?
Ears How are the ears and hearing? Running ears? Poor hearing? Ringing ears?
Nose How are your nose and sinuses? Stuffy nose? Discharge? Bleeding? Unusual odors?
Mouth Any problems with your mouth? Sores? Bad taste? Sore tongue? Gum trouble?
Throat and neck Any problems with your throat and neck? Sore throat? Hoarseness? Swelling? SwalloWing?
Breasts Any problems with your breasts? Lumps? Nipple discharge? Bleeding? Swelling? Tendemess? Pulmonary Any problems With your lungs or breathing? Cough? Sputum? Bloody sputum? Pain In the chest on taking a deep
breath? Shortness of breath?
Cardlovascu ar Do you have any pro blems WI th your he a rt?Ch es t pai'n?, Shor tness 0 f '0 rea th? Pa Ip l' t at 'I ons?. Co ug h?, Sw e IIIng 0
ankles? Trouble lying fiat in bed at night? Fatigue?
Gastrointestinal How is your digestion? Any changes in your appetite? Nausea? Vomiting? Diarrhea? Constipation? Changes in your
bowel habrts? Bleeding from the rectum? Hemorrhoids?
Genitourinary Male: Any problems with your kidneys or urination? Painful urination? Frequency? Urgency? Nocturia? Bloody or cloudy
urine? Trouble starting or stopping?
Female: Number of pregnancies? Abortions? Miscarriages? Any menstrual problems? Last menstrual period? Vaginal
bleeding? Vaginal discharge? Cessation of periods? Hot flashes? Vaginal itching?
Endocrine Any problems with your endocrine glands? Feeling hot or cold? Fatigue? Changes in the skin or hair? Frequent
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 Medicine and Rehabilitation. Braddom, Randall L. MD,Edition: 3rd. Publisher: Saunders, W. B.. ISBN: