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...
TRANSCRIPT
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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
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History Taking
A. 主訴
B. 病情演變及其時程 (present illness)
C. Positive findings and negative findings
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History Taking
D. Personal profileE. Past HistoryF. Allergic History G. Family History H. Travel history
I. Review of System
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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
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Diagnostic spectrum
Mono..(1) Oligo..(2-4) Poly..(>=5)OA OA OASeptic Psoriatic PsoriaticGout Reactive RAPseudo gout Enteropathic Crystal
AS CTDs Septic Sarcoid Sarcoid
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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
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偶發性 :
游走性 :
加成性 :
發炎強度
時間
Pain-free interval
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偶發性 :
游走性 :
加成性 :
發炎強度
時間
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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
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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
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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
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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
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Stiffness
Morning stiffness > one hour Improved after exercise
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Weakness
Weakness vs muscular weakness
D/D muscular weakness Proximal muscle / distal muscle Symmetric / asymmetric Diurnal change
D/D neurologic problems
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Constitutional symptoms ( 全身症狀 )Fever infection ? Autoimmune disease ( SLE, vasculitis. Adult onset still’s disease ) Malignancy FatigueBody weight loss
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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
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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
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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
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History taking
A. 主訴
B. 病情演變及其時程 (present illness)
C. Positive findings and negative findings
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Personal history
SmokingAlcoholism Betnut chewingSocial history ( 社交 )Economic status ( 社經地位 )Family and marriage Psychiatric status
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Personal history
Sexual history a. Reiter’s syndrome b. Gonadococcal arthritis c. AIDS d. others………
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Past history
Blood transfusionViral Hepatitis history Hepatic dysfunction TB ( pul. / Extra-pul )Thyroid disease Gestational history ( abortion ?! ) Malignancy
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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
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Allergic history and travel history Drug allergic history -- What drug -- What symptoms/signs -- How to management
Travel history
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Past history
Pregnancy-- GnPmSA?-- Spontaneous abortionMajor surgeryOral contraceptive pills Psychiatric history
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Family history
•Sibling or parents with autoimmune diseases
AS, SLE, RA, Gouty arthritis, seronegative spondyloarthropathy,Nodular OA ( hands ), Marfan’s syndrome
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Evaluation and drug compliance
Medication ( duration, effects, side effects and dosage )
Compliance !!
Rehabilitation ( esp. myofascial pain )
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Operation / biopsy history
Operative history ( esp. articular)Kidney biopsySynovial membrane biopsy Skin biopsy
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Selected symptoms reviewsGeneral
Fever / fever type
Fatigue
Shaking chills
Body weight loss
Intercurrent illness
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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
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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
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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
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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
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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
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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
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Systemic lupus erythematosus
SLE : -- Initial presentation -- Criteria -- SLEDAI -- Lupus nephritis data charts -- Antiphospholipid antibody syndromes
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Rheumatoid arthritis
Active synovitis : identify the active synovitis by figures ** pre-MTP pulse and post-MTP pulse
Extra-articular symptoms
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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
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Polymyositis / dermatomyositis Muscle weakness : proximal /distal
EOM ? Neurosensory deficits ?
Skin sign : Gottron’s signs; helitrope’s eyes ; malar rashes Arthritis Dysphageal SOB, chest tightness
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Adult Onset Still’s Disease
Fever patterns -- spiking ( noctural fever ) Prodromal symptoms -- Sore throat Associated symptoms -- rashes / Arthritis / arthralgia
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Sjogren’s syndrome
Subject dry eyesSubject dry mouth
Other symptoms
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Ankylosing spondylitis
Onset ages : Pain patterns : -- alternative buttock pain with/without radiation -- peripheral arthritis/arthralgia Eye involvement : uveitisEnthesopathy ( heel pain )
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Seronegative spondyloarthropathy
Skin symptoms Uretheral/genital symptoms Ocular symptomsArticular distributions -- Axial / peripheral -- Large / small Nails Enthesopathy
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Special charts
Description of clinical findings 關節圖章皮膚圖章
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Thanks for your attention