ASSESSMENT KFR

SUPERVISOR :
DR. TERTIANTO PRABOWO, SP. KFR (K), AIFO
EVALUATION OF THE PATIENT

• Why the need evaluation of the patient on PMR?

a. The symptoms and signs required for the diagnosis of disability are not synonymous with those required for the
diagnosis of disease.
b. There is no one to one correlation between a disease & the spectrum of disability problems that may be
associated with it. The disability is dependent on the patient’s total requirements.
c. There is no one to one relationship between a disease & the amount of residual disability. Disability problems
can be removed even though the disease is unchanged.
d. The ability of a patient and a physician to remove disability in the face of chronic disease is dependent on the
residual capacity of the patient for physiological and psychological adaptation. The patient’s residual strengths
must be evaluated and built upon to “work around” impairment to remove disability.
EVALUATION OF THE PATIENT
PATIENTS TREATMENT PROCESS

4 PHASES :
PHASES 1  History and physical examination
PHASES 2  Identifies specific problem list from data base
PHASES 3  Identifies specific treatment for each problem
PHASES 4  describes effectiveness of each problem, describe subsequent alteration in
each depending o patient progress
EVALUATION OF THE PATIENT

• Initial evaluation  more detailed & comprehensive than subsequent / follow-up evaluations.
• Exception : when a patient is seen for a follow-up visit with new signs/symptoms.
• Physiatric history and physical examination :
 traditional format + additional emphasis on history, signs, symptoms that affect function
(performance).
 also identifies those systems not affected that might be used for compensation.
• Identifying & treating primary impairments to maximize performance
EVALUATION OF THE PATIENT
1. History.
Chief complaint, present illness, social & vocational history, review of
systems, past medical history.
2. Physical Examination.
Skin, eyes, ears, mouth & throat, cardiovascular system, respiratory system,
genitalia & rectum, neurological examination, musculoskeletal system,
functional neuromuscular, and mental status.
5. Problem List.
Subjective data, Objective data, Assessment, Plan  SOAP
HISTORY
• Chief complain  existence of disability
• Present illness  extent of lost function in basic self activities
• Social and vocational history  evaluates environment and provides insight in
psychological make-up the patient
• Review of system and past medical history  assessment ofresidual capacity
HISTORY

Chief Complaint
 symptom / concern that caused patient to seek medical treatment because of their
changes in health
• Outpatient : pain, weakness, gait disturbance of various musculoskeletal / neurologic
origins.
• Inpatient : mobility, ADL, communication, cognitive deficits & candidacy for inpatient
rehab.
• Specific circumstance of a patient offering a chief complaint  can also allude to a
degree of disability/handicap  example, obese mail carrier with chief complaint of
difficulty in walking because of knee pain could suggest not only impairment but also
impact on his vocation & role as a provider for his family (participation, handicap).
HISTORY

History of the Present Illness

 details the chief complaint & any related/unrelated functional deficits, other information relating
to chief complaint (recent & past medical/surgical procedures, complications of treatment, potential
restrictions/precautions).
• Include some/all of 8 components related to chief complaint: location, time of onset, quality,
context, severity, duration, modifying factors, associated signs & symptoms.
• Example: 70-year-old man referred by neurologist for physical therapy because cannot walk
properly (chief complaint). Over past few months (duration), slowly progressive weakness of his
left leg (location). Subsequent workup suggested amyotrophic lateral sclerosis (context). patient
was active in his life & working up until a few months previously, ambulating without an assistive
device (context). Now he uses straight cane for fear of falling (modifying factor). Besides difficulty
with walking, patient also has some trouble swallowing foods (associated signs&symptoms).
HISTORY

1. Ambulation
2. Transfer activities
3. Dressing activities
4. Eating skills
5. Personal hygiene
6. Communication
HISTORY

Assisstence in one of following categories :

1. Standy assistance
Activities performed by the patient, assistance “standing by” to guard against the occurrence of
accidents
2. Partial physical assistance
The patient could do a good part but not all of it alone. The assistantant then provides partial
physical assistance
3. Total physical assistance
For the activity to be accomplished, the assistant has o do all of it
HISTORY

Mobility
• Mobility : ability to move about in
one’s environment.
• Functional mobility 
independence & safety, including
the use of / need for mobility
assistive devices (crutches, canes,
walkers, orthoses, manual & electric
wheelchairs)
HISTORY
Ambulation
• Ambulation: travel from one place to another over a finite distance.
• How far / for how long patients can walk, whether require assistive devices, need for
rest breaks.
• Any symptoms associated with ambulation: chest pain, shortness of breath, pain,
dizziness.
• History of falling / instability while walking, ability to navigate uneven surfaces.
• Stair mobility, along with the number of stairs patient must routinely climb &
descend at home / in community, presence/absence of handrails.
HISTORY

Transfer History
• Transfer: movements that involve changes of position in place  more basic than
ambulation.
• Include activities going from bed to a wheelchair or regular chair; going from
wheelchair to a toilet or car; going from wheelchair or regular chair to a standing
position.
• Sample questions to begin on assessment of disability in transfer abilities:
1. Can you get in and out of bed unaided?
2. Can you get on and off a toilet unaided?
3. Can you get in and out of the tub unaided?
HISTORY

Activities of Daily Living and Instrumental Activities of Daily Living

• ADL  activities required for personal care : feeding, dressing, grooming, bathing, toileting.
• I-ADL  more complex tasks required for independent living in immediate environment :
care of others in household, telephone use, meal preparation, house cleaning, laundry, & in
some cases use of public transportation.
• Identify & document ADL can & cannot perform, determine causes of limitation.
• Example: a woman with stroke might state that she cannot put on her pants  could be due
to a combination of factors such as a visual field cut, balance problems, weakness, pain,
contracture, hypertonia, or deficits in motor planning  Some of these factors can be
confirmed later in PE.
• A more detailed follow-up to a positive response to the question is frequently needed.
(example: patient might say “yes” to “Can you eat by yourself?”  further questioning, it
might be learned that she cannot prepare food by herself / cut food independently.
HISTORY
HISTORY
Communication History
• Communication activities include the spectrum of skills associated with listening, speaking, reading, and writing.
• Demonstrates the breadth and depth of language function  dependent upon the patient’s education and
intellectual level.
• Listening and reading skills  dependent upon the integrity of the auditory and visual organs.
• Speaking and writing skills  dependent upon the integrity of the motor functions associated with articulation
and hand dexterity.
• Examiner needs to direct the inquiry to family members or others who have a recent and a-long standing
relationship with the patient.
• Sample questions to explore the communication area:
1. Do people have trouble understanding your speech?
2. Do you have trouble understanding what other people are saying?
3. Do you have difficulty reading newspapers?
4. Is writing difficult for you?
REVIEW OF SYSTEMS THE ABILITY OF A PATIENT AND THE PHYSICIAN TO REMOVE DISABILITY IS
DEPENDENT ON THE PATIENT’S RESIDUAL CAPACITY.
HISTORY

Past Medical History

• Provides information on the residual capacity of the patient.
• Concurrent disease or previous trauma and surgery may have produced residual
impairments. Although these impairments no longer produce disability themselves,
they may compound the disability of the present illness when added to the new
impairments.
•  allows physiatrist to understand how preexisting illnesses affect current status,
how to tailor the rehabilitation program for precautions & limitations.
• A careful past medical history review  an essential component of the evaluation of
a patient with disability.
 HISTORY

Social and Vocational History

 To obtain information on patient ability to adjust to the stress of chronic disability & early
identified the psychological problems that may need to be dealt with. Divided into 3
categories:
• Social History
 Compromised patient’s family unit, when dependency on others for the performance of basic self care
occurs, or if a job is lost because of disease.
 A major disability of one member of a family unit will create problems of adjustment for all and even
threaten the integrity of the unit.
 The assessment of social impairment is obtained from inquiries into the stability of the family unit, the
history of the unit, the resources within the unit, the responsibilities of the patient within the unit, and
the physical environment of the home and the community.
HISTORY

 Home environment & living situation : lives in urban/suburban/rural, lives in a

house/apartment, elevator access, wheelchair accessible, stairs, bathroom accessible from
bedroom, bathroom has grab bars/handrails.
 If no caregiver at home  home health aide.
 Family and friends support : Patients who have lost function  require supervision,
emotional support, physical assistance. (Family, friends, neighbours)  level of assistance
they are willing and able to provide.
 Patients with pain and/or depression are at risk for further abuse  referred to social
work.
HISTORY

• Vocational History
 A patient’s disease may also produce the disability of unemployment  requires understanding of
the physical, intellectual, and interpersonal requirements of the patient’s job.
 Source of financial security; relates to self-confidence & identity.
 If the patient has not been working, inquire into the current sources of financial support & their
sufficiency.
 Education, recent work history, ability to fulfil job requirements subsequent to injury/illness.
 If cannot fully regain previous function level  vocational options available should be explored.
HISTORY

 Work environment can be modified to compensate for functional loss / ↓musculoskeletal

pain complaints. (ex: installation of a wheelchair ramp for accountant with paraplegia).
 Avocational activities are also an important aspect of a patient’s function  many patients
derive more of their enjoyment of live from their avocational pursuits than vocational
activities. Sample questions:
1. What do you do with your leisure time and on weekend by yourself? With your family?
2. What organizations or religious groups are you active in?
3. When did you last participate in these activities?
HISTORY
Social and Vocational History
• Pscychological History
 Psychological function needs to be assessed in patient with a chronic illness/physical disability
because:
1. Since the organic pathological changes may be incompletely reversible  present the stress of
the disease  may become great magnitude stress.
2. The patient and the family may have to relinquish established goals and old ways of doing things
 have to learn new ways that are not always consistent with personality, or not the patient’s
preferred way of doing things, even often not society’s preferred way.
3. The patient’s psychological make-up needs to be understood and to be facilitated in treatment
 to motivate the patient and reinforce new learning is necessary.
HISTORY
Social and Vocational History
4. Patients with brain damage from trauma/disease  need understanding of intellectual
function  need to be trained successfully in the removal of disability in the basic functions.
 Psychological problems should be included in the patient’s problem list, when the reaction
to the stress of the disease is inappropriate or insufficient; and new learning is not
occurring during treatment.
  collecting information about the patient’s basic personality.
 Interpretation: the patient’s previous life style; past history or response to ordinary life
stresses; current response to the stress of the disease; the activities to motivate the
patient.
THANK YOU 
THE PROBLEM LIST
• The problem oriented approach to medical management  a helpful technique in the
management of patient with disability.
• The problem oriented approach to tracing the course of a problem includes:
1. The recording of subjective (S) data (patient symptoms & personal impressions).
2. The recording of objective (O) data (patient physical signs, laboratory & other test data).
3. The assessment (A) of the problem (the interpretation of subjective and objective data
into an impression of the status of the problem).
4. The plan (P) (the necessary additional consultations, diagnostics, therapeutics, or patient
education required).
• Thus the acronym SOAP serves as a means of organizing continuing management.
• Diagnosis of disease alone is insufficient for the planning of a comprehensive rehabilitation treatment
SUMMARY
program.
• The symptoms & signs required to diagnose disease are not synonymous with the symptoms & signs required
to diagnose disability.
• To diagnose the disability (specific losses in physical, social, vocational, and psychological functions) requires
investigations not ordinarily considered in the treatment of acute short term disease.
• To achieve a successful treatment program that removes disability, the physician must understand his patient’s
residual strength.
• Once the problem list established, the rehabilitation treatment process can begin  specific plan for each of
the problems on the list.
• It succeeds when each of the problems is solved to the highest degree obtainable by available therapeutic
techniques:
1. Methods to prevent or correct secondary problems.
2. Methods to enhance the capability of systems unaffected by the disease.
3. Methods to enhance the functional capacity of affected systems.
4. Methods to promote function through the use of adaptive equipment.
5. Methods to modify the social and vocational environment.
6. Methods from psychological theory to enhance patient performance.