History Taking of AIR 台中榮民總醫院 過敏免疫風濕科 謝佳偉醫師 陳得源主任...

History Taking of AIR

台中榮民總醫院 過敏免疫風濕科謝佳偉醫師 陳得源主任 藍忠亮主任

History Taking

A. 主訴

B. 病情演變及其時程 (present illness)

C. Positive findings and negative findings

History Taking

D. Personal profileE. Past HistoryF. Allergic History G. Family History H. Travel history

I. Review of System

Arthritis VS Non-arthriticular Synovitis Non-articular

Swelling

關節上下左右都會腫脹較廣泛性

局限於關節某一部位

Tender 關節任一處均有壓痛 局限某一點或 Vague

Stiffness

> 30 minutes < 30 minutes

ROM Passive = active Passive > active

ESR Increased Normal

Diagnostic spectrum

Mono..(1) Oligo..(2-4) Poly..(>=5)OA OA OASeptic Psoriatic PsoriaticGout Reactive RAPseudo gout Enteropathic Crystal

AS CTDs Septic Sarcoid Sarcoid

Arthritis/arthralgiaDescription of articular symptoms:

Onset : Time: Abrupt Acute: minutes to hours Insidious Subacute : hours to days Gradual Chronic : 2 weeksDuration :Character: 1. Intermittent 2. Migratory : 淋病性關節炎 or Rheumatic fever 3. Addictive

偶發性 :

游走性 :

加成性 :

發炎強度

時間

Pain-free interval

偶發性 :

游走性 :

加成性 :

發炎強度

時間

偶發性

游走性

加成性

發炎強度

時間

第一個關節痛到最痛時、第二個關節開始疼痛 第二個關節痛到最痛時、第一個

關節已經不痛

沒有 pain-free interval

Arthritis/arthralgiaDescription of articular symptoms:

Type of joint: 1. Large/ small 2. Axial / peripheral, 3. Upper / lower, 4. Symmetry /asymmetry

Type of symptoms: Pain, Stiffness, Erythema Swelling Warm Loss of motionExternal factors affecting symptoms

風濕病的症狀

疼痛 晨間僵硬 腫脹軟弱無力全身症狀雷諾氏現象

疼痛 – I •一指法 : localized the location of pain•Arthritis / soft tissue ? •Patterns•Exacerbating factors / releaving factors •何時最痛 ? -- morning stiffness -- night pain

Stiffness

Morning stiffness > one hour Improved after exercise

Weakness

Weakness vs muscular weakness

D/D muscular weakness Proximal muscle / distal muscle Symmetric / asymmetric Diurnal change

D/D neurologic problems

Constitutional symptoms ( 全身症狀 )Fever infection ? Autoimmune disease ( SLE, vasculitis. Adult onset still’s disease ) Malignancy FatigueBody weight loss

Raynaud’s phenomenon ( 雷諾現象 )3-phase or 2-phase color change Pale purple Red Pale purple ** numbness, pain, tingling, heat

** MCTD, PSS, SLE, Sjogren’s syndrome, CREST syndrome

Arthritis / arthralgia 肌肉關節以外的症狀1. Prodromal presentation2. Fever/ chills3. Hair loss / oral ulcers / malar rashes4. Raynaud’s phenomenon5. Morning stiffness6. Muscular weakness/ proximal /distal7. Dry eyes, dry mouth8. Heel pain / lower back pain9. Genital ulcer / urethritis 10. Skin rashes / skin ulcers

Sicca complex Dry eyes: a. 眼睛有乾澀感 b. 眼睛有異物感 c. 眼睛經常疼痛Dry mouth : a. 無法連續講話，必須喝水潤喉才能順利講完 b. 吞東西時發生困難 ( 乾飯、餅乾、蛋黃 ) c. 半夜要起來喝水 d. 唾液腺是否曾腫大現象

History taking

A. 主訴

B. 病情演變及其時程 (present illness)

C. Positive findings and negative findings

Personal history

SmokingAlcoholism Betnut chewingSocial history ( 社交 )Economic status ( 社經地位 )Family and marriage Psychiatric status

Personal history

Sexual history a. Reiter’s syndrome b. Gonadococcal arthritis c. AIDS d. others………

Past history

Blood transfusionViral Hepatitis history Hepatic dysfunction TB ( pul. / Extra-pul )Thyroid disease Gestational history ( abortion ?! ) Malignancy

Medication history

Past use and present use ( 中藥、草藥、健康食品、維他命等 )

Drug-induced lupus Sulfa --- SLE Drug-induced nephropathy Drug allergy

Allergic history and travel history Drug allergic history -- What drug -- What symptoms/signs -- How to management

Travel history

Past history

Pregnancy-- GnPmSA?-- Spontaneous abortionMajor surgeryOral contraceptive pills Psychiatric history

Family history

•Sibling or parents with autoimmune diseases

AS, SLE, RA, Gouty arthritis, seronegative spondyloarthropathy,Nodular OA ( hands ), Marfan’s syndrome

Evaluation and drug compliance

Medication ( duration, effects, side effects and dosage )

Compliance !!

Rehabilitation ( esp. myofascial pain )

Operation / biopsy history

Operative history ( esp. articular)Kidney biopsySynovial membrane biopsy Skin biopsy

Selected symptoms reviewsGeneral

Fever / fever type

Fatigue

Shaking chills

Body weight loss

Intercurrent illness

Selective Review of System-Skin Alopecia Levido reticularis Malar rash Skin dystrophic change

Photosensitivity TelangiectasisDiscoid rash Psoriasis

Other skin rash Mechanic’s hand

Raynaud’s phenomenon

Periungal telangiectasia

Skin ulcers, digital Periungal erythema Skin ulcers, non-digital Hypo/hyperpigmentation Petechia PurpuraPitting nails Onycholysis / onychodystrop

hy

Selected symptoms reviewsENT Chest

Conjunctivitis Chest pain, pleuritic

Uveitis Chest pain, others

Dry eyes Dyspnea

Dry mouth Orthopnea

Mucosal ulcers ( pain ?) Chest tightness

Nasal lesions Hemoptysis

Salivary gland enlarge. Wheezing

Headache Lymphadenopathy

Selected symptoms reviews

GI GU

Dysphagia ** Genital ulcers

Abdominal pain ** Hematuria by history

Diarrhea Proteinuria by history

Melana/ hematemesis Renal stone

Nausea/ vomiting Urethral discharge

Peptic ulcer syndromes

Menstrual abnormality

Selective review of SystemMusculo-skeletalArthralgia Heel pain

Arthritis Sausage fingers/toes

Jaccoud deformity Muscle weakness

Morning stiffness Proximal/distal

Buttock pain c/ diurnal change

Lumbasacral pain Muscle atrophy

Cough pain

Selected symptoms reviews

Hematologic Neuromuscular

Anemia by history Seizure

Neutropenia by history Thrombocytopenia by Hx

Muscle pain Claudication

Muscle weakness ( proximal/distal )

Neurologic sign

Psychiatric disorders

HCV and Cryoglobulinemia

Blood transfusion

Viral hepatitis history

Tattoo ( 紋眉 , 紋身 , 紋眼 )

Drug addiction ( drug abuse ) 共用不潔針頭

Systemic lupus erythematosus

SLE : -- Initial presentation -- Criteria -- SLEDAI -- Lupus nephritis data charts -- Antiphospholipid antibody syndromes

Rheumatoid arthritis

Active synovitis : identify the active synovitis by figures ** pre-MTP pulse and post-MTP pulse

Extra-articular symptoms

Scleroderma ( PSS )

History of exposure to 氯化乙烯 , 矽膠

Raynaud’s phenomenon Puffy hands / swollen fingers Sclerodactyly Dysphageal Chest tightness and SOB Periungal telangiecatsis

Skin description : hyper/hypopigmentation

Polymyositis / dermatomyositis Muscle weakness : proximal /distal

EOM ? Neurosensory deficits ?

Skin sign : Gottron’s signs; helitrope’s eyes ; malar rashes Arthritis Dysphageal SOB, chest tightness

Adult Onset Still’s Disease

Fever patterns -- spiking ( noctural fever ) Prodromal symptoms -- Sore throat Associated symptoms -- rashes / Arthritis / arthralgia

Sjogren’s syndrome

Subject dry eyesSubject dry mouth

Other symptoms

Ankylosing spondylitis

Onset ages : Pain patterns : -- alternative buttock pain with/without radiation -- peripheral arthritis/arthralgia Eye involvement : uveitisEnthesopathy ( heel pain )

Seronegative spondyloarthropathy

Skin symptoms Uretheral/genital symptoms Ocular symptomsArticular distributions -- Axial / peripheral -- Large / small Nails Enthesopathy

Special charts

Description of clinical findings 關節圖章皮膚圖章

Thanks for your attention