Introduction to the Physiatric ExaminationJohn M Lavelle, D.O.Spine Physiatrist

Rehabilitation EvaluationEvaluation of FunctionEncompasses the entire general medical history and physical examinationMust ascertain the functional consequence of the medical diagnosis/disease that constitutes the rehabilitation diagnosisDetermine impairment and treat to prevent or minimize disability and handicap

Rehabilitation EvaluationIt is comprehensive not limited to a single organ systemAttention paid to whole personReturn person to the fullest possible mental physical social and economic independence

Patient HistoryChief ComplaintHPIFunctional HistoryPMHxFHxSHxSxHxMedsROS

Chief ComplaintPts primary concern in his or her own wordsTypically an impairment in the form of a symptom that implies a certain diseaseMy hands ache and go numb when I driveCarpal Tunnel

HPIStory of the medical problemLISTENGently guide the conversationDocument handedness

Onset, location, duration, quality, context, severity, modifying factors (aggravating/alleviating), and associated S&S, other treatments

Functional HxCharacterizes the disabilities that have resulted from the disease and documents remaining capabilities.Also document level of function prior to disease.Discuss: Communication, eating, grooming, bathing, toileting, dressing, transfers, mobility.

ADLs/iADLsActivities of daily living (ADLs)- bathing, toileting, dressing, eating, hygiene & grooming

Instrumental ADLs- meal preparation, laundry, telephone use, home maintenance, pet care

Communication

HearingSpeakingReadingWriting

EatingDifficulty leads to aspiration pneumonitis, malnutrition and depression.

Can tolerate solids vs liquids?

GroomingInability can impact body image and self esteem, social sphere and vocational opportunities.

BathingCan lead to obvious psychosocial issues.Inability causes skin maceration and ulceration, infections and spread of diseases.

ToiletingIncontinence of stool or urine to the cognitively intact person can be very detrimental psychosocially.Impairs social and employment opportunities.Loss of dignityLeads to skin breakdown, infections, ulcers.Check indwelling caths

Dressing

We dress to go out of the house. Dependence in dressing causes severe limitations in independence.

Transfers/Mobility

How get around?Bed mobilityAround house/communityWheelchair mobility, ambulation, driving & devices required

PMHxComorbidities importantCharacterize the patient's baseline functional level.Diagnosis and Impact of specific conditions- cardiopulmonary, musculoskeletal, neurologic & rheumatologic

ROSNeed 10!HEENTNeuroCVRespGIGUSkinMSKEndoID

Social HxFamily: married, kids Home environment: architectural barriers- stairs, elevator, small houseSupport: family and friends support systemsPsychiatric HistoryHow deal with stress, anxiety issues, depressionDiet adequate nutrition important

Social HxSubstance abuse: EtOH, Illicits, Tobacco Vocation: work/education Sexual historyLifestyle: Recreational activities: reading sports, etc ExerciseSpiritualityFinances: disability, unemployment

Litigation

Family HxHereditary diseasesh/o anxiety, depression, chronic pain, arthritis, CVA, MI, etc

Physical ExaminationVitals: Temp, Hr, RR, BP, SiO2, I/Os, PainSkin/lymphatics: turgor, color, swellingHead: lacerations, deformities, inequalitiesEyes: ptosis, symmetric, visionEars: hearing, wax, bleedingMouth and Throat: Moist membranes, masses, tongue/uvula midline, gagNeck: JVD, ROM

PEChest: symmetric, excursionHeart and Lungs: Auscultate!Abdomen: BS, palpateGU: Urinating (I/Os), foley, ED?GI: Rectal, hemorrhoids

MSKInspect: asymmetry, wastingA/PROMPalpate: muscles, joint stability

Neuro

Mental Status: LOC: Orientation Attention Recall Gen fund of knowledge Calculations Proverbs Leave no stone unturnedA rolling rock never grow mossIf you play with fire you get burned. JudgementsWhat would you do if a fire alarm goes offWhat do if you found stamped, addressed envelope

NeuroSpeech and LanguageWernicke: receptive aphasia-impaired comprehensionBroca: expressive aphasia - non-fluentGlobal: non-fluent, poor comprehensionTranscortical motor: good comprehension, preserved repetition, reduced speechTranscortical sensory; poor comprehension, good repetition, fluent speechConduction: reduced repetition

NeuroCranial Nerves

NeuroMuscle tone spasticity, rigidity, hypotonicity Coordination FNF, HTSInvoluntary movtsPerception agnosia, Rt/Lt neglectMMT, DTRs, Sensation

Functional ExamEating, groomin, bathing, dressing, toiletingTransfersMobility

Functional capabilityLevel of independence in: Ambulating Communicating Dressing Eating,Personal Hygiene Transfers

AssesmentDiagnosis & Description of status (improving, stable, declining)ie: improving Lt hemi 2/2 Rt MCA CVA due to hypertensive episode.Eligibility for Acute rehabilitation (ability to participate in 3 hours of rehabilitation per day, as well as identifiable benefit from OT/PT/Speech Therapy)Setting for further interventions if not acuteHome: 24hr supervision, Day Rehab, outpatient PT/OT/RNSNFLTAC

PLANList by system or problem with treatment plan:Neuro:CVA- admit to acute rehab for .CV: HTN cont metorpolol, goal SBP 140-160Provide prognosis: Good recovery: able to return to work or schoolModerate disability: able to live independently; unable to return to work or schoolSevere disability: able to follow commands/unable to live independentlyPersistent vegetative state: unable to interact with environment; unresponsiveRecommendation goals: short and long term

History of PM&RPhysiatry derives from the Greek words physikos (physical) and iatreia (art of healing). Separate medical specialty since 1947. Written accounts of physical techniques for healing can be seen as far back as the writings of Hippocrates in 400 B.C. Formal education for Physiatry had its beginning in 1926 when, after service in the U.S. Army during World War I, Dr. John Stanley Coulter joined the faculty of Northwestern University Medical School as the first full-time academic physician in physical medicine.

History of PM&RDr. John Stanley Coulter initiated the first continuing teaching program in physical medicine.Consisting of short courses of three to six month's duration for physicians in practice 1930's brought further organization and purpose to the field of rehabilitation. Training programs for physical therapy technicians existed, but these were standardized by the formation of The American Registry of Physical Therapists Frank Krusen, MD, established the Physical Medicine Program at the Mayo Clinic in 1936 and initiated the first three-year residency in Physical Medicine. Drs. Coulter and Krusen led the organization of the American Academy of Physical Medicine in 1938

History of PM&RDr. Krusen coined the word "PhysiatristDescribed the small group of physicians who were dedicated to the approach of adding physical medicine to medical therapeutics to treat neurological and musculoskeletal disorders

Krusen wrote the first textbook on Physical Medicine in 1941. He is recognized as the "Father of Physical Medicine."

In 1946, the AMA Council on Physical Medicine voted to sponsor the term "physiatrist" (fizz-ee-at'-trist) and physiatry (fizz-ee-at'-tree) with the accent on the third syllable

History of PM&RHoward A. Rusk, MD, an internist, as a result of his experience in the Army Air Corps Convalescent and Rehabilitation Services at Jefferson Barracks in World War II, recognized that passive, inactive, non-physical convalescence resulted in both physical and emotional deterioration of soldiers recovering from accident or illness.

Dramatic and more rapid recovery of strength and endurance and the much more rapid return to active duty due to the benefits of planned aggressive rehabilitation Army Air Corps extended the program to all of its hospitals, and shortly thereafter, it was extended throughout the military services. The Medical War Manpower Board recognized the great value of active rehabilitation and introduced it into civilian medical practice.

History of PM&RRusk went to New York's Bellevue Hospital where he began his 30-year campaign to train physicians and establish rehabilitation programs to treat the whole patient.

Rusk's earned recognition as "the Father of Rehabilitation Medicine.

History of PM&RBy 1946, 25 medical residencies or fellowships in PM&R had been established.

In January 1947, the Advisory Board of Medical Specialties (now the American Board of Medical Specialties) formally recognized the American Board of Physical Medicine. Two years later, at the urging of Dr. Rusk, the name was changed to include "Rehabilitation."

Thank You