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
I. Review of System
Arthritis VS Non-arthriticular
Synovitis
Swelling
Tender
Non-articular
關節上下左右都會腫 局限於關節某一
脹較廣泛性
部位
關節任一處均有壓痛 局限某一點或
Vague
> 30 minutes
< 30 minutes
ROM
Passive = active
ESR
Increased
Passive >
active
Normal
Stiffness
Diagnostic spectrum
Mono..(1) Oligo..(2-4) Poly..(>=5)
OA
Septic
Gout
Pseudo gout
OA
Psoriatic
Reactive
Enteropathic
AS
Septic
Sarcoid
OA
Psoriatic
RA
Crystal
CTDs
Sarcoid
Arthritis/arthralgia
Description of articular symptoms:
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
Pain-free
interval
偶發性:
游走性:
發
炎
強
度
加成性:
時間
偶發性:
游走性:
發
炎
強
度
加成性:
時間
偶發性
游走性
發
炎
強
度
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
加成性
時間
Arthritis/arthralgia
Description 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
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
Fatigue
Body 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 presentation
2. Fever/ chills
3. Hair loss / oral ulcers / malar rashes
4. Raynaud’s phenomenon
5. Morning stiffness
6. Muscular weakness/ proximal /distal
7. Dry eyes, dry mouth
8. Heel pain / lower back pain
9. 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
Smoking
Alcoholism
Betnut chewing
Social 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 transfusion
Viral 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 abortion
Major surgery
Oral 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 biopsy
Synovial membrane biopsy
Skin biopsy
Selected symptoms reviews
General
Fever / fever type
Fatigue
Shaking chills
Body weight loss
Intercurrent illness
Selective Review of SystemSkin
Alopecia
Levido reticularis
Malar rash
Skin dystrophic change
Photosensitivity
Telangiectasis
Discoid rash
Psoriasis
Other skin rash
Raynaud’s phenomenon
Skin ulcers, digital
Skin ulcers, non-digital
Mechanic’s hand
Periungal telangiectasia
Periungal erythema
Hypo/hyperpigmentation
Petechia
Pitting nails
Purpura
Onycholysis /
onychodystrophy
Selected symptoms reviews
ENT
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
Dysphagia **
Abdominal pain **
Diarrhea
Melana/ hematemesis
Nausea/ vomiting
Peptic ulcer syndromes
GU
Genital ulcers
Hematuria by history
Proteinuria by history
Renal stone
Urethral discharge
Menstrual abnormality
Selective review of System
Musculo-skeletal
Arthralgia
Arthritis
Jaccoud deformity
Morning stiffness
Buttock pain
Lumbasacral pain
Cough pain
Heel pain
Sausage fingers/toes
Muscle weakness
Proximal/distal
c/ diurnal change
Muscle atrophy
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 eyes
Subject dry mouth
Other symptoms
Ankylosing spondylitis
Onset ages :
Pain patterns :
-- alternative buttock pain
with/without radiation
-- peripheral arthritis/arthralgia
Eye involvement : uveitis
Enthesopathy ( heel pain )
Seronegative
spondyloarthropathy
Skin symptoms
Uretheral/genital symptoms
Ocular symptoms
Articular 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