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Author: Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation
Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of
Neurology, Penn State Milton S. Hershey Medical Center and Penn State University
College of Medicine
Contributor Information and Disclosures
Updated: Jun 23, 2009
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In the inpatient setting, physiatrists are consulted when the patient has progressed to
medical stability but is not capable enough with regard to self-care, feeding,
communicating, managing bowel and bladder function, and ambulating to be discharged
home. The adult physiatric history and physical examination provides advice on the
appropriate level of rehabilitation services required to assist the patient. The appropriate
level of care may range from admitting the patient to an inpatient rehabilitation facility to
outpatient therapy services to home health therapy services. This makes physiatrists the
first choice for medical directorship in an inpatient rehabilitation facility.
Physiatrists typically practice in urban and suburban settings where the demand for services
is greatest, but some have found success in rural settings.4
The physiatrist is expected to have mastered the established and evolving biomedical and
clinical information applicable to the clinical care of patients with a wide range of
impairments, disabilities, diseases, and disorders. In addition, the physiatrist is expected to
demonstrate strong interpersonal skills to communicate effectively with allied health
professionals such as physical, occupational, and speech therapists. Physiatrists are
recognized as effective members or leaders of a multidisciplinary team.
The attributes of a successful physiatrist include the ability to review and synthesize
historical information, perform a focused medical and functional examination, formulate a
diagnosis that correlates to the clinical findings, and construct a comprehensive treatment
and/or management program.
In summary, the adult physiatric history and examination represent a value-added service,
recognizing functional ability as an important component of the overall picture of a
patient's health.
are incorporated into the history of the present illness. The past medical history serves as a
review of all the patient's significant medical treatments, previous hospitalizations, and
surgical procedures.
The systems review screens for current and past symptoms that may represent concurrent
problems not readily identified in the history of the present illness. Consider constitutional
(fever, chills), head and neck (swallowing difficulties, visual/auditory changes),
cardiovascular chest pain or palpitations), respiratory (shortness of breath), genitourinary
(urinary retention or incontinence), gastrointestinal, neurological, and musculoskeletal
symptoms in the review. The physiatrist elicits information about the presence of any
allergies caused by medications or environmental sources, along with a brief description of
allergic reactions.
The functional history characterizes the extent to which a disability may have resulted from
an illness or chronic disease. The functional history details the patient's life in a
chronological manner, starting with the level of education, domestic situation (eg, married,
children), current employment/vocational history, avocational pursuits, dietary habits,
tobacco and alcohol consumption, driving ability, and typical information regarding the
patient's performance of activities of daily living (ADL). Consider describing instrumental
activities of daily living (IADL), such as the ability to manage money, prepare meals, go
grocery shopping, and perform household chores. This information may help the physiatrist
place the disease, injury, or illness into the context of the patient's previous level of
functioning in cases involving long-term care financing.
Questions about the domestic situation may include a description of the patient's home (eg,
ranch-style versus colonial) and location of essential rooms, such as the bedroom,
bathroom, and kitchen. Knowledge of the location of stairs is important since steps may
represent potential architectural barriers to the patient returning home. In the case of a
patient with a history of falling, knowledge of the floor surfaces (eg, carpet, rugs) may
provide an insight into the factors contributing to falls.
Review of the patient's employment/vocational history contributes to a better understanding
of how the recent illness or disease affects the patient's societal obligations. A selfemployed patient may view any further hospitalization as an unnecessary expense and may
forego needed rehabilitation services. On the other hand, a patient with a life-altering
disease or illness may need future vocational rehabilitation services. The information
collected initially plays an important role in instituting future vocational rehabilitation
services.
The patient's avocational pursuits may have no immediate bearing on the decision to pursue
inpatient rehabilitation services; however, the information obtained may contribute to the
emotional well-being of the patient requiring further rehabilitation services and may
provide positive reinforcement.
The designation activities of daily living refers to feeding, grooming, bathing, dressing, and
toileting. The patient's ability to perform each of these activities with or without assistance
is crucial to determining what future services the patient may need to return home. In the
inpatient hospital setting, inability to perform these basic tasks may preclude discharging
the patient directly home. Details on the patient's level of function prior to hospitalization
help to establish a benchmark of performance that the patient may be expected to achieve
as a condition for returning home. Information on functional level may determine the most
appropriate alternative setting after discharge from the hospital and rehabilitation unit if the
patient is deemed unable to return directly home. The medical history and general health of
individuals close to the patient (eg, spouse) become important in discharge planning and/or
long-term care.
Physical Examination
The physical examination is the integration of information obtained by inspection,
palpation, percussion, and auscultation of the patient to gather the physical findings in
support of the diagnoses suggested from the history of the present illness. The examination
may uncover physical findings not readily apparent to the patient or not suggested by the
history.6,7,8
All physical examinations contain 1 or more elements of the following systems or body
areas presented below in a general head-to-toe direction. When an impairment is identified,
the appropriate regional examination is expanded.
Head, eyes, and ears - General appearance, deformities, assistive devices (eg,
hearing aids, glasses), and visual/auditory acuity
Mouth, throat, and nose - General appearance, general dental condition, and patency
of airway
Neck - General appearance, vascular distension, auscultation for bruits, and active
range of motion (ROM) and passive ROM
Functional
o Assessment of transfer from supine to sitting position to standing position
and of standing balance
o Assessment of gait
o Assessment of balance in static and dynamic situations
o Assessment of nonphysiologic behaviors like Waddell signs (eg, superficial
skin tenderness, stimulation of back pain by axial loading or truck rotation,
differences in straight leg raising response between supine and sitting
positions, regional nonanatomic weakness or numbness, and
overreaction/disproportionate pain responses)
o Caty et al found that self-assessments of locomotor ability by adult stroke
patients, using the ABILOCO questionnaire, correlated closely with thirdparty assessments of these patients made by physical therapists and by an
independent medical examiner.9 The study utilized 28 patients, who
answered the questionnaire between 3 weeks and almost 5 years after
suffering a stroke. The investigators concluded that the ABILOCO
questionnaire provides a valid means in clinical practice and research of
assessing locomotion in patients who have had a stroke.
History of falls, possibly due to antalgic gait pattern from rheumatoid arthritis and
possible environmental factors (eg, throw rugs on floors)
History of phlebitis in a patient with a right hemiarthroplasty and Coumadin use for
prevention of deep vein thrombosis (DVT)
Reactive depression to suggestions that she may not be able to return home or drive
again
Physical therapy evaluation and training for (1) bed mobility, (2) transfer, (3) mat
exercises to strengthen the right leg affected following surgery, while promoting
strengthening and reconditioning following surgery, (4) promoting optimum gait
patterns to maximize the use of the right leg while preventing antalgic gait patterns
from affecting the contralateral hip further, (5) ascending and descending stairs, (6)
balance, and (7) education in hip ROM and positioning to lessen the chances of hip
dislocation
Once produced, the IME becomes a medicolegal document read by all participants in the
process. Physician-patient confidentiality is not associated with this type of examination,
and no physician-patient relationship is established. The IME commences with the patient's
account of the history of the events from the time of injury to the present. The physiatrist
attempts to detail the mechanism of injury, symptoms at the time of injury, and the events
that followed as described by the patient and compares this information with the medical
records for consistency.
The patient's past medical history is scrutinized carefully for possible preexisting conditions
that may have contributed to the symptoms by temporary exacerbation or by aggravation,
which is considered a physical change and, therefore, is more serious. Current complaints
are defined through the patient's report of the pain symptoms, their location, pattern, and
intensity and an account of what aggravates and ameliorates the symptoms.
Functional status is assessed with the patient's report on tolerance to various activities (eg,
sitting, standing, walking) and ability to perform ADL. The patient's representation of
functional status may be compared to the physician's observations or the medical record for
consistency of reporting. The occupational and psychosocial histories are reviewed in
particular detail. Knowledge of the patient's job description at the time of injury can aid in
determining causality. Likewise, a functional capacity assessment must start from the basis
of the job requirements. The work history may illuminate the patient's feelings about work,
which in turn may assist the physiatrist reach an objective evaluation of subjective
complaints, formulate a prognosis, and establish a reasonable return-to-work determination.
The physical examination may be complete or regional. Both types of examinations should
document positive, negative, and nonphysiologic findings. Document behavioral
observations along with physical findings. Begin either type of physical examination with
taking of vital signs (eg, height, weight, blood pressure, heart rate). Note behavior during
the history-taking portion of the examination. In the history, address duration of sitting,
general movements, and irregularities in ambulation. The patient also can be observed for
aberrant behavior, unusual postures, or evidence of symptom magnification.
In appropriate settings, the patient's ability to undress in preparation for the examination
may contribute information about functional ability and functional ROM. In all
circumstances, however, the patient's privacy and dignity must be respected.
A structural examination begins with an inspection of the patient in the standing position,
noting cervical, thoracic, and lumbar curvature. Document any scars, tattoos, assistive
devices, or other individual physical features noted during physical examination. Identify
sites of tenderness to palpation and percussion by anatomic landmarks.
Assessments of ROM of the spine are made with a goniometer or inclinometer positioned
against the skin. ROM tests are performed for a minimum of 3 trials to obtain an average
rating. A wide variation in each measurement may indicate lack of consistency on the
patient's part. ROM is tested in all extremities for active and passive effort. Straight leg
raising (SLR) exercises are used for the lower extremities to elicit back pain. The SLR may
be performed in supine and sitting positions. Discrepancies in performance (eg, SLR supine