Upload
candice-hamilton
View
262
Download
13
Embed Size (px)
Citation preview
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