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분야
pptxChief complaint
Present Illness1
Past medical history
Physical Examination1
Musculoskeletal examination
Problem list
Initial assessment
Diagnostic plan
Laboratory findings1
Radiographic finding1
Assessment
Therapeutic plan
Lower back의 활동시 간헐적 pain
Morning stiffness 1시간 이상
Hypertension (telmisartan 복용 중)
Colon cancer s/p colectomy and chemotherapy
BMI : 25.25kg/m2 경도비만
Occupation : 농부
Lt. 5th PIP joint의 swelling, tenderness
Both 1st MCP joints의 swelling, tenderness
Rt. 2nd MCP joints의 tenderness
Both wrists 의 swelling과 tenderness
Neck pain
Both shoulders 의 tenderness
Both knees 의 tenderness
Both ankles 의 swelling과 tenderness
Both leg radiation pain
Laboratory study
Complete Blood Count
Serum Electrolytes
Liver Function Test
Urine Analysis
ESR, CRP
RF, Anti-CCP Ab
Imaging study
Both hand X-ray
Both knee X-ray
Both elbow X-ray
Both shoulder X-ray
Both foot X-ray
C-spine X-ray
Chest PA
Both ankle X-ray
L-S spine X-ray
R/O rheumatoid arthritis
Classification criteria for RA(score-based algorithm : add score of categories A-D:
a score of ≥6/10 is needed for classification of a patient as having difinite RA)
Joint involvement
1 large joint (0)
2-10 large joints(1)
1-3 small joints(with or without involvement of large joints) (2)
4-10 small joints(with or without involvement of large joints) (3)
>10 joints(at least 1 small joint) (5)
Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA (0)
Low-positive RF or low-positive ACPA (2)
High-positive RF or high-positive ACPA (3)
Acute-phase reactants(at least 1 test result is needed for classificaion)
Normal CRP and normal ESR (0)
Abnormal CRP or abnormal ESR (1)
Duration of symptoms
< 6 weeks (0)
≥ 6 weeks (1)
