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1、2015年,风湿免疫科入门及关节查体,ABC of Rheumatology&Examination of Joints,1,目录,1,风湿病问诊要点,2,关节查体,2,风湿病问诊要点,3,一般原则：一般按时间顺序展示症状的进展关节症状：,表现：红、肿、热痛、僵直、活动受限 部位：单/少/多、外周/中轴、对称/非对称、关节本身/关节周围组织、固定/游走/渐增 诱因：药物、感染、饮食、活动、外伤 病程：急性/慢性，发作性/进展性,1.a 风湿病问诊要点关节症状,4,全身症状：,发热、消瘦、疲倦、盗汗 提示：全身病情活动、血管炎、副肿瘤综合征、感染,1.b 风湿病问诊要点关节外症状,皮肤：,颧部红
2、斑、光过敏、脱发 硬指、雷诺现象 肢端溃疡、皮肤/粘膜溃疡、紫癜、结节 生殖器病变 皮肤病史：银屑病、皮肤过敏,5,心肺：,呼吸困难、咳嗽、咯血、咳痰 胸膜性或心包性胸痛 浮肿、运动耐量下降 肺栓塞、肺高压,1.b 风湿病问诊要点关节外症状,肾脏：,蛋白尿、血尿 结石、夜尿增多、软瘫 少尿,6,胃肠道：,反流、吞咽困难 腹痛、腹泻、便血 肝功能异常、黄疸,1.b 风湿病问诊要点关节外症状,血液：,血细胞计数：WBC、Hb、PLT 出凝血异常：流产、不明原因的DVT或PE 异常骨痛 血清学：自身抗体,7,神经肌肉：,PNS：单神经/多发单神经/周围神经病 CNS：精神病、认知障碍、头痛、视力、T
3、IA/卒中、抽搐 肌肉：肌痛/压痛、肌无力、呛咳,1.b 风湿病问诊要点关节外症状,内分泌：,甲亢/甲减 垂体 肾上腺轴异常表现,8,既往感染史：结核、乙肝/丙肝、机会性感染用药史：毒品、PTU、etc.月经史：经量多、不规律、闭经婚育史：习惯性流产家族史：SpA、其它CTD、肾病史、遗传病史,1.c 风湿病问诊要点其他病史,9,Examination of Joints,10,视诊,2.关节查体,Examination of Joints,Inspection,触诊,Palpation,动诊,Passive and active range of motion,肌力,Muscle stren
4、gth,整体功能,Integrated function,11,视诊,2.关节查体,Examination of Joints,Inspection,触诊,Palpation,动诊,Passive and active range of motion,肌力,Muscle strength,整体功能,Integrated function,12,视诊,2.关节查体,Examination of Joints,Inspection,触诊,Palpation,动诊,Passive and active range of motion,肌力,Muscle strength,整体功能,Integrate
5、d function,13,视诊,2.关节查体,Examination of Joints,Inspection,触诊,Palpation,动诊,Passive and active range of motion,肌力,Muscle strength,整体功能,Integrated function,14,视诊,2.关节查体,Examination of Joints,Inspection,触诊,Palpation,动诊,Passive and active range of motion,肌力,Muscle strength,整体功能,Integrated function,15,2.关节
6、查体,Examination of Joints,-脊柱,Spine,16,2.关节查体,Examination of Joints,-脊柱,Spine,17,2.关节查体,Examination of Joints,-脊柱,Spine,18,2.关节查体,Examination of Joints,-下颌关节,Temporomandibular Joint,19,2.关节查体,Examination of Joints,-下颌关节,Temporomandibular Joint,20,2.关节查体,Examination of Joints,-肩关节,Shoulder,21,2.关节查体,E
7、xamination of Joints,-肩关节,Shoulder,22,2.关节查体,Examination of Joints,-肘关节,Elbow,23,2.关节查体,Examination of Joints,-肘关节,Elbow,24,2.关节查体,Examination of Joints,-手腕及手掌,Wrist and Hand,25,2.关节查体,Examination of Joints,-手腕及手掌,Wrist and Hand,26,2.关节查体,Examination of Joints,-髋关节,Hip,27,2.关节查体,Examination of Joint
8、s,-髋关节,Hip,28,2.关节查体,Examination of Joints,-髋关节,Hip,29,2.关节查体,Examination of Joints,-髋关节,Hip,30,2.关节查体,Examination of Joints,-膝关节,Knee,31,2.关节查体,Examination of Joints,-膝关节,Knee,32,2.关节查体,Examination of Joints,-膝关节,Knee,33,2.关节查体,Examination of Joints,-足,Foot,34,2.关节查体,Examination of Joints,-足,Foot,35,2.查体要点,Key Points,1.必须 亲自查看患者！（你的想法常常会在看到患者后改变，即使是短短一瞥）2.大多数RF阳性的患者不是RA；大多数ANA阳性的患者不是SLE。3.结缔组织病患者如出现发热，应首先考虑感染和其它非风湿病原因，而不是原发病活动。死于感染的患者要远远多于死于基础病的患者。4.除外风湿病要远远比确诊风湿病困难。,36,谢谢聆听,37,
