Historytaking-台中荣民总医院.ppt

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 Arthritis/arthralgiaDescription of articular symptoms: 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 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 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 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. Positiv