风湿性疾病的骨表现英语课件

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Rheumatology:ClinicalSkillsApproachtotheMusculoskeletalHistory2ObjectiveAttheendofthesession,youwillbeabletoDescribe3properwaysofaskingquestions(dynamic)ListanddescribethecomponentsofmusculoskeletalhistoryListanddescribe8componentsinthehistoryofpresentillness3WhatIstheRoleofaPhysician?Helpthepatienthelphimself/herself4HowDoesaPhysicianHelpaPatientAccuratediagnosisAnatomicPathophysiologicSpecificDevelopamanagementplanwiththepatientandthepatient’sfamilyNonpharmacologicPharmacologicSpecific5HowDoesaPhysician

MakeanAccurateDiagnosisPhysicianasa“medicaldetective”InterviewwitnesshistoryGatherphysicalevidencesPhysicalexaminationDoingtests(DNAetc)Laboratory/imaging6TheMusculosketalHistoryAnaccuratehistoryistheessentialfirststepinassessinganymedicalproblemThedynamicandmechanicalaspectsofamedicalhistoryisthesameforanymedicalproblem(notjustformusculoskeletalhistory)Thedifferenceisinthespecificissueswithpathologyindifferentorgans/systemse.g.Differentissueswithhypertensionversusmusculoskeletaldisease7DynamicstoElicit

anAccurateMedicalHistoryBreaktheiceLetthepatientdescribetheproblemListencarefully,showyourinterestandconcernAskcommon-sense,understandableandopenendedquestions(ifpossible)8Mechanics:

ComponentsofaMedicalHistoryAge,GenderChiefcomplaintHistoryofpresentillnessMedicationsAllergiesPastMedicalHistoryReviewofSystemsFamilyHistorySocialHistory9ChiefcomplaintThemainreasonwhythepatientvisitsyouUsuallythefirstcomplaintgivenafterbeingasked“whatistheproblem”or“whyareyouseeingmetoday”leadsintothe“Historyofpresentillness”.Whatifthepatientcontinuestalkingabouteverythingelse,orhasmultiplecomplaints??AcknowledgeandasktoprioritizeLetpatientknowthatyouwilldealwithothercomplaints10HistoryofPresentIllnessExplorethechiefcomplaint“OLDCARTS”OnsetLocation/radiationDurationCharacterAggravationfactorsRelivingfactorsTimingandSeverityAddextra-articularfeaturesandfunctionallimitations11PastMedicalHistoryProperdynamicOpenendedquestionsUsuallyincludeHospitalizationMedicalillnessSurgeryMajorinjuries/traumaExplorespecificareasdependingonthesystem/organOftenthesewillcomeupinReviewofSystems12MedicationsNotjustforthepresentingproblemPrescriptionNonprescriptionSupplementsComplimentaryalternativemedicine13AllergiesAnyknown“drug”allergy14ReviewofSymptomsHeadandneckCardiac/vascularRespiratoryAbdominal/GastrointestinalGenitourinaryDermatologicNeurologicHematologicInRheumaticDiseasesSkinhaireyesinflammationdrynessRaynaud’sMucosalulcersSunsensitivity151616ReviewofSymptomsrheumatoidFamilyHistoryManyautoimmune,metabolicdiseasessharegeneticsusceptibilityPatientsmaybemoreconcernaboutthisMayhelpindiagnosisFamilyhistoryofpsoriasis:considerpsoriaticarthritisMayhelpintreatmentselectionFamilyhistoryofmultiplesclerosisinapatientwithRA:noantiTNF17SocialHistoryOccupationMaritalStatus,ChildrenAccommodationSmoking,Alcohol,StreetDrugsTuberculosisexposureTravel18HowDoestheMusculoskeletalHistoryHelptoEstablishaDiagnosisAnatomicPathophysiologicSpecific19HowDoesaPhysicianHelpaPatientAccuratediagnosisAnatomicPathophysiologicSpecificDevelopamanagementplanwiththepatientandthepatient’sfamilyNonpharmacologicPharmacologicSpecific20Case35yearoldman“Doc.myshoulderhurts”–ChiefcomplaintWhatareyougoingtodo?TakeanX-ray?NO,NO,takeagoodhistoryfirst.21HistoryofPresentIllnessExplorethechiefcomplaint“OLDCARTS”OnsetLocation/radiationDurationCharacterAggravationfactorsRelivingfactorsTimingandSeverityAddextra-articularfeaturesandfunctionallimitations22ShoulderPain:AnatomicSkinPeriarticularArticularReferred23ShoulderPain:PathophysiologicInflammationInfectionAutoimmunecrystalMechanicalTraumaWearandtearInfiltrative24ShoulderPain:SpecificDiagnosisRotatorcufftearSubacromialbursitisBicepstendonitisSupraspinatuscalcifictendonitisHumeralfractureOsteoarthritisRheumatoidarthritisLungcancerThoracicoutletsyndromeCervicalradiculopathyCholecystitis25HistoryofPresentIllnessExplorethechiefcomplaint“OLDCARTS”OnsetLocation/radiationDurationCharacterAggravationfactorsRelivingfactorsTimingandSeverityAddextra-articularfeaturesandfunctionallimitations26OnsetProgressionHowandwhendiditstartAcuteTraumatic,inflammatoryHowhasitprogressedGradualoveryears,progressiveWearandtearNotlikelytraumatic,infiltrative27OnsetProgressionSampleQuestionsOnsetWhendidthisstart?Hasthiseverhappenedbefore?Diditcomeonsuddenlyorgradually?Whatdoyouthinkcausedthepain?ProgressionHasthepaingoneupanddownsinceorsteadilybecameworse?Howlonghasitbeen?Whatiswrongwiththesequestions28LocationDistribution

SampleQuestionsWhereisyourpain?Canyoupointtoitwithonefinger?Doesitradiate?Wheredoesitradiateto?Doyouthinkit’syourmusclesorthejoints?29LocationDistributionBespecific:jointversusbetweenjointsButbeawareofthefrequencyofreferredpain;e.g.,cardiacpain,neckpainAskpatienttopointtoareaofpainPatient’sconceptofhipmaynotbecorrect;e.g.,buttock=hipformanypatientsAfterpatientnamessymptomaticjoints,inquirespecificallyaboutALLjoints3030LocationDistribution3131RAOAGoutASDurationOftenthisisalreadycoveredintheonsetprogressionsection32Character:QuantityandQualityTellmeaboutyourpainOftenofnodiagnosticimportanceIfcharacterofsymptomchanges,consideradifferentproblem33AggravatingRelievingFEATUREINFLAMMATORYMECHANICALAMStiffness>1hr<30minutesFatigueSignificantMinimalActivityMayimproveMayworsenRestMayworsenMayimproveSystemicInvolvementYesNoSteroidresponsiveYesYes/No3434Inflammatoryvs.MechanicalMorningNightPainSeverityInflammatoryMechanical35TimingFEATUREINFLAMMATORYMECHANICALAMStiffness>1hr<30minutesFatigueSignificantMinimalActivityMayimproveMayworsenRestMayworsenMayimproveSystemicInvolvementYesNoSteroidresponsiveYesYes/No3636FunctionalLimitationWillhelpindeterminingtreatmentFunctionallimitsmaybeduetomorethanjusttheM