1、A.I.R.OrientationFor new staff Staff Dr.李修身 Dr.陳天令 Dr.黃章喜(R5)Allergy,Immunology,RheumatologyStudy:Teaching:1.Morning meeting(W3 and W5,7:45 am at 6F MICU meeting room)2.Radiology-Rheuma combined meeting(once a month,W4,4:00 pm at Radiology Department 4F meeting room)3.病房主任病房主任 teaching(at least 4 ti
2、mes a month,2 months/year)4.Clerk teaching(usually W4,W5&W6,scheduled by 醫醫教部教部)5.Bed side teaching(any time)免疫風濕疾病相關症狀免疫風濕疾病相關症狀 a)關節症狀關節症狀:觀察病人是否真的關節腫或是軟組織腫？觀察病人是否真的關節腫或是軟組織腫？是否有紅腫熱痛，是否有關節液？是否有紅腫熱痛，是否有關節液？(bulgesign).是否是否有晨僵大於一小時情形？是否有晨僵大於一小時情形？是否symmetric？受影響之關？受影響之關節區域節區域(Mono/Oligo/poly)？發作的情形？
3、持續或陣發性？發作的情形？持續或陣發性?是周邊或中樞關節？急性或慢性是周邊或中樞關節？急性或慢性(持續存在六星期持續存在六星期)？b)皮膚症狀皮膚症狀:觀察病人是否有觀察病人是否有MalarRash,Discoidrash,Photosensitivity,Oralulcer,Skinulcer,Genitalulcer,Heliotropessign,Shawlssign,Pittingnail,Gottronspapule,Mechanichands,Raynaudsphenomenon,psoriasis.c)掉髮、掉髮、眼睛乾燥、眼睛乾燥、口乾、口乾、血管炎。血管炎。d)持續不明原因的
4、發燒，持續不明原因的發燒，肌肉疼痛或乏力肌肉疼痛或乏力。e)最近使用之藥物及過敏史最近使用之藥物及過敏史,相關疾病之家族史相關疾病之家族史。After admission#Infection or inflammation?=priority:the one which is life-threatening#If no old chart=病歷查詢病歷查詢,報告查詢報告查詢(OPD and Lab)#Rx may as OPD unless contraindication(e.g.drug adverse effects)1.Hypersensitivity:NSAIDs,DMARDs,a
5、ntibiotics,(anaphylaxis,urticaria,angioedema,Steven-Johnson syndrome)*dilantin,bactrium,tegretal,allopurinol 2.Idiosyncratic reaction:antithyroid drugs,immunosuppressants 3.Discomfort:any drug 4.Overdose:hypoglycemic agents,hypnotics,acetaminophenRoutine Examination a)WBC-DC,Hb,Hct,MCV,platelet,ESR,
6、CRP b)Sugar,BUN,Cr,Na,K,GOT,GPT,Albumin,TG,Chol,U.A.(MAR)c)Urineroutine,CCr,Dailyurineprotein d)STS-RPR,stoolOB e)ChestPA,12-leadEKG f)Heartecho:pericardialeffusion時或其它時或其它CV問題問題。g)腹部腹部Echo:ascites,serositis,肝脾腫大肝脾腫大,排除感染排除感染。h)肺功能肺功能:Vasculitis,Sjogren,RA,DM/PMorSLE會併發會併發Interstitialpneumonitis。i)X
7、-rayofinvolvedjoints。AIR 相關之檢驗 a)RF,ANA,C3,C4(CH50),若入院時，門診已有測過若入院時，門診已有測過ANA且結果為陽性且結果為陽性,則可測則可測Anti-ds-DNA,有分有分免疫方法免疫方法(dilutiontiter)及及核醫方法核醫方法(unit),並做並做ENA screening(ExtractableNuclearAntigen).b)ENAscreeningAnti-Sm(懷疑為懷疑為SLE病人時病人時),Anti-RNP(MCTD),Anti-SSA/SSB(乾燥症乾燥症),Anti-Scl70(PSS)c)PT:normal,P
8、TT:prolongedLupus Anticoagulant(LA),Anti-cardiolipin Ab(IgG/IgM)Antiphospholipidsyndrome.d)Anemiasurvey:lowerMCV:Ferritin,Fe,TIBC,必必要時做要時做Hb電泳電泳.e)HLA-B27,IgG/M/A/E,Cryoglobulin,c/p-ANCA f)Thyroidfunctiontest,CPK,#ENA screen test and Anti-Sm/Anti-RNP#ENA screen test and Anti-SSA/Anti-SSB#Anti-ds-DNA
9、:63129(核醫單)and 66632(免疫單)#Before scheduled major operation:DC aspirin 1 week earlier DC NSAIDs for 3-4 T1/2 and keep using COX-2 specific NSAIDs and nonactylated salicylate#MAST and CAP:allergen detection#Muscle biopsy:special stain available (外送萬芳醫院 pathologist),=notify the Surgeon for collecting f
10、resh muscle specimen =notify Pathology Dept.for preparing solutionAIR 相關procedurea)a)ShirmerShirmers test:s test:淚腺功能檢查。淚腺功能檢查。b)Scialoscintigraphyb)Scialoscintigraphy:檢查唾液腺之功能檢查唾液腺之功能c)Whole body bone scan(Tcc)Whole body bone scan(Tc-99m)-99m)d)Gad)Ga-67 inflammation scan-67 inflammation scane)Skin
11、 biopsy,kidney biopsy,lip biopsy,muscle biopsye)Skin biopsy,kidney biopsy,lip biopsy,muscle biopsyf)Joint&soft tissue Echo(W2 pm)f)Joint&soft tissue Echo(W2 pm)g)NCV,EMGg)NCV,EMGh)Pathergyh)Pathergy test testi)Joint aspiration,intra-articular i)Joint aspiration,intra-articular injectioninjectionj)Ar
12、throscopyj)Arthroscopyk)Angiographyk)AngiographyAntinuclear antibody (ANA)HomogenousPeripheralSpeckledNucleolar,HCV(Rheumatoid arthritis)(Rheumatoid arthritis)C spine AP view(open mouth)C spinelateral view(flexion)#NSAIDs in MMH1.Salicylic acids:a.Acetylated:aspirin(infant tapal,Bokey)b.Nonacetylate
13、d:choline magnesium trisalicylate(Trilisate)2.Acetic acids:a.Indole derivatives:indomethacine(Indocin)b.Phenylacetic acid:diclofenac(Kataflam,Voltaren-S,Vetin Inj.)c.Etodolac(Lonine*)3.Propionic acids:a.Naproxen(Naposin)b.Ketoprofen(Ketoprofen)c.Tiaprofenic acid(Synotec)d.Ketorolac tromethamine(Keto
14、,&Keto Inj.).(50 y-o,or SLE(專案)Gout with renal impairment1.Sulindac(馬偕無)2.Non-acetylated salicylate(Trilisate)3.COX-2 selective NSAID*(Lonine,Mobic,NO-TON)4.COX-2 specific NSAID*(Celebrex,Vioxx)5.Corticosteroid6.Colchicine7.Lower dose allopurinol Gout with PUD(UGI bleeding)1.NSAID(*&*)or corticosteroid prn2.Intra-articular injection3.Colchicine4.H2-antagonist(4 months),PPI(2 months)5.Misoprostol(專案，一年份)Thanks!
