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History Taking of AIR

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 profile E. Past History F. Allergic History G. Family History H. Travel history

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History Taking of AIR

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  1. 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

  2. History Taking • A.主訴 • B.病情演變及其時程 (present illness) • C. Positive findings and negative findings

  3. History Taking • D. Personal profile • E. Past History • F. Allergic History • G. Family History • H. Travel history • I. Review of System

  4. Arthritis VS Non-arthriticular

  5. Diagnostic spectrum Mono..(1) Oligo..(2-4) Poly..(>=5) OA OA OA Septic Psoriatic Psoriatic Gout Reactive RA Pseudo gout Enteropathic Crystal AS CTDs Septic Sarcoid Sarcoid

  6. Onset : Time: Abrupt Acute: minutes to hours Insidious Subacute : hours to days Gradual Chronic : 2 weeks Duration : Character: 1. Intermittent 2. Migratory : 淋病性關節炎or Rheumatic fever 3. Addictive Arthritis/arthralgiaDescription of articular symptoms:

  7. 偶發性: 游走性: 加成性: Pain-free interval

  8. 偶發性: 游走性: 加成性:

  9. 偶發性 游走性 加成性 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

  10. 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 motion • External factors affecting symptoms

  11. 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

  12. 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

  13. Stiffness • Morning stiffness > one hour • Improved after exercise

  14. Weakness • Weakness vs muscular weakness • D/D muscular weakness • Proximal muscle / distal muscle • Symmetric / asymmetric Diurnal change • D/D neurologic problems

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

  16. 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

  17. Arthritis / arthralgia • 肌肉關節以外的症狀 • Prodromal presentation • Fever/ chills • Hair loss / oral ulcers / malar rashes • Raynaud’s phenomenon • Morning stiffness • Muscular weakness/ proximal /distal • Dry eyes, dry mouth • Heel pain / lower back pain • Genital ulcer / urethritis • Skin rashes / skin ulcers

  18. 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

  19. History taking • A.主訴 • B.病情演變及其時程 (present illness) • C. Positive findings and negative findings

  20. Personal history • Smoking • Alcoholism • Betnut chewing • Social history ( 社交 ) • Economic status ( 社經地位) • Family and marriage • Psychiatric status

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

  22. Past history • Blood transfusion • Viral Hepatitis history • Hepatic dysfunction • TB ( pul. / Extra-pul ) • Thyroid disease • Gestational history ( abortion ?! ) • Malignancy

  23. 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

  24. Allergic history and travel history • Drug allergic history -- What drug • -- What symptoms/signs • -- How to management • Travel history

  25. Past history • Pregnancy-- GnPmSA?-- Spontaneous abortion • Major surgery • Oral contraceptive pills • Psychiatric history

  26. Family history • Sibling or parents with autoimmune diseases • AS, SLE, RA, Gouty arthritis, seronegative spondyloarthropathy, • Nodular OA ( hands ), Marfan’s syndrome

  27. Evaluation and drug compliance • Medication ( duration, effects, side effects and dosage ) • Compliance !! • Rehabilitation ( esp. myofascial pain )

  28. Operation / biopsy history • Operative history ( esp. articular) • Kidney biopsy • Synovial membrane biopsy • Skin biopsy

  29. Selected symptoms reviews

  30. Selective Review of System-Skin

  31. Selected symptoms reviews

  32. Selected symptoms reviews

  33. Selective review of System

  34. Selected symptoms reviews

  35. 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

  36. Systemic lupus erythematosus • SLE : -- Initial presentation • -- Criteria -- SLEDAI -- Lupus nephritis data charts • -- Antiphospholipid antibody syndromes

  37. Rheumatoid arthritis • Active synovitis : identify the active synovitis by figures ** pre-MTP pulse and post-MTP pulse • Extra-articular symptoms

  38. 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

  39. Polymyositis / dermatomyositis • Muscle weakness : proximal /distal • EOM ? • Neurosensory deficits ? • Skin sign : Gottron’s signs; helitrope’s eyes ; malar rashes Arthritis • Dysphageal SOB, chest tightness

  40. Adult Onset Still’s Disease • Fever patterns -- spiking ( noctural fever ) • Prodromal symptoms -- Sore throat • Associated symptoms -- rashes / Arthritis / arthralgia

  41. Sjogren’s syndrome • Subject dry eyes • Subject dry mouth • Other symptoms

  42. Ankylosing spondylitis • Onset ages : • Pain patterns : -- alternative buttock pain with/without radiation -- peripheral arthritis/arthralgia • Eye involvement : uveitis • Enthesopathy ( heel pain )

  43. Seronegative spondyloarthropathy • Skin symptoms • Uretheral/genital symptoms • Ocular symptoms • Articular distributions -- Axial / peripheral -- Large / small • Nails • Enthesopathy

  44. Special charts • Description of clinical findings 關節圖章 • 皮膚圖章

  45. Thanks for your attention

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